Nancy G. Stevens

A Five-Step “Microskills” Model Of Clinical Teaching

Teaching family practice residents in a clinical setting is a complex and challenging endeavor, especially for community family physicians teaching part-time and Junior faculty members beginning their academic careers. We present a five-step model of clinical teaching that utilizes Simple, discrete teaching behaviors or “microskills.” The five microskills that make up the model are (1) get a commitment, (2) probe for supporting evidence, (3) teach general rules, (4) reinforce what was done right, and (5) correct mistakes. The microskills are easy to learn and can be readily used as a framework for most clinical teaching encounters. The model has been well received by both community family physicians interested in teaching and newer residency faculty members.

The Effect of Differences in Objective and Subjective Definitions of Childhood Physical Abuse on Estimates of Its Incidence and Relationship to Psychopathology.

The relationship between objective and subjective definitions of physical abuse and the lifetime prevalence of depression was examined in 280 women attending a family medicine clinic at a large medical center. Based on their responses to a detailed questionnaire regarding discipline and abuse in childhood, 28.2% of these women were objectively defined as abused. Only 11.4% subjectively defined themselves as abused. The proportion of women who experienced depression during their lifetime was highest among those who defined themselves as abused (83%), intermediate among those who met objective criteria for having been physically abused, but did not define themselves as such (56%), and lowest among those who did not meet objective criteria for a history of physical abuse (35%). Similar relationships were found for history of psychotherapy, receipt of psychoactive medication, history of hospitalization for depression, suicide attempts and self-injury.

Genetics in Primary Care: A USA Faculty Development Initiative

The Genetics in Primary Care (GPC) project is a USA national faculty development initiative with the goal of enhancing the training of medical students and primary care residents by developing primary care faculty expertise in genetics. Educational strategies were developed for the project by an executive committee with input from an advisory committee, comprising individuals with primary care, medical education and genetics expertise. These committees identified the key issues in genetics education for primary care as (1) considering inherited disease in the differential diagnosis of common disorders; (2) using appropriate counseling strategies for genetic testing and diagnosis, and (3) understanding the implications of a genetic diagnosis for family members. The group emphasized the importance of a primary care perspective, which suggests that the clinical utility of genetic information is greatest when it has the potential to improve health outcomes. The group also noted that clinical practice already incorporates the use of family history information, providing a basis for discussing the application of genetic concepts in primary care. Genetics and primary care experts agreed that educational efforts will be most successful if they are integrated into existing primary care teaching programs, and use a case-based teaching format that incorporates both clinical and social dimensions of genetic disorders. Three core clinical skills were identified: (1) interpreting family history; (2) recognizing the variable clinical utility of genetic information, and (3) acquiring cultural competency. Three areas of potential controversy were identified as well: (1) the role of nondirective counseling versus shared decision-making in discussions of genetic testing; (2) the intrinsic value of genetic information when it does not influence health outcomes, and (3) indications for a genetics referral. The project provides an opportunity for ongoing discussion about these important issues.

Collaborative Care Model to Improve Outcomes in Major Depression

OBJECTIVE: To develop a pharmacist intervention to improve depression care and outcomes within a primary care setting. METHODS: Pragmatic, randomized trial of a clinical pharmacist collaborative care intervention versus usual care in a busy, academic family practice clinic. RESULTS: Seventy-four patients diagnosed with a new episode of major depression and started on antidepressant medications were randomized to enhanced care (EC) or usual care (UC) groups. EC consists of a clinical pharmacist collaborating with primary care providers (PCPs) to facilitate education, initiation, and titration of acute-phase antidepressant treatment to monitor treatment adherence and to prevent relapse. Control patients receive UC by their PCP. The main end point is reduction of depression symptoms over time as measured by the Hopkins Symptom Checklist (SCL-20). Other outcomes include the Diagnostic and Statistical Manual of Mental Disorders, (DSM-IV) criteria for major depression, health-related quality of life measured by the Medical Outcomes Study Short Form 12 (SF-12), medication adherence, patient satisfaction, and healthcare utilization. The main end point and the cost of treating major depression will be used to estimate the cost-effectiveness of the collaborative care model. CONCLUSIONS: The study is a unique, ongoing trial that may have important implications for the treatment of depression in primary care settings as well as new roles for clinical pharmacists.

A case-control study to evaluate efficacy-of screening for faecal occult blood

Objectives — Faecal occult blood testing is routinely used for early detection of colorectal cancer, but evidence of its efficacy in preventing death from colorectal cancer is limited. A case-control study was carried out to evaluate whether screening for faecal occult blood is associated with a reduced risk of fatal colorectal cancer. Setting — A health maintenance organisation in western Washington State, which has offered its members faecal occult blood testing every two years since 1983. Methods — Cases (n = 248) were members of the health maintenance organisation who died from colorectal cancer between 1986 and 1991. For each case,. two control subjects, who did not die from colorectal cancer and who were similar to each case in age, gender, and year of enrolment at the health maintenance organisation, were randomly selected from the membership list of the year in which the case was diagnosed (n = 496). Information about episodes of faecal occult blood testing (including the location and reason for the test, and the evaluation of positive tests) and potential confounders was obtained from medical records. Results — Cases were less likely than controls to have ever been screened (odds ratio (OR) =0·7, 95% confidence interval (CI) 0·5 to 1·0), consistent with a beneficial impact of screening. There was little difference, however, for screening that had taken place within a three year period before diagnosis (OR = 0·9, 95% CI 0·6 to 1·2), the maximum interval during which most tumours ought to have been detectable by faecal occult blood testing. A reduction in risk was seen for home testing but not for office testing, and in individuals aged less than 75 but not in those aged 75 or older. Although most of the 21 controls with a positive faecal occult blood test underwent some additional testing, only five (24%) were evaluated with colonosocopy or air contrast barium enema. Conclusions — While there can be uncertainty as to whether specific faecal occult blood tests were performed as screening or diagnostic tests, those performed at home and in younger persons may be relatively less likely to be diagnostic tests that were misclassified as screening. Thus the modest reduced risk associated with faecal occult blood testing in these settings/persons may reflect genuine benefit. However, the presence of a reduced risk associated with a screening faecal occult blood test received in the past, well before a tumour or polyp might bleed enough to allow detection, is compatible with uncontrolled confounding. Interpretation is further complicated by the fact that a number of individuals in the study group who had positive test results underwent limited or no diagnostic testing. Thus our results should be interpreted with considerable caution.

Placental hemorrhagic endovasculitis: Risk factors and impact on pregnancy outcome

Two hundred and eighteen cases of hemorrhagic endovasculitis (HEV), a recently recognized abnormality of human placentas, were identified from placentas submitted to the Michigan Placental Tissue Registry over a 2.5‐year period. HEV appears to focus on fetal placental blood vessels with resultant fragmentation and destruction of fetal RBCs, hemorrhage into villous stroma, microthrombi in villous capillaries and non‐exudative necrosis of medium sized chorionic vessels. Placentas without HEV submitted for evaluation from the same hospitals were selected for comparison. Women with HEV placentas were of similar age, race and parity as control women. The sex of the fetus of HEV cases was somewhat more often female (57% vs 48%, P = 0.05). The presence of HEV appeared to have a deleterious effect on the outcome of pregnancy: 52% (112/218) of the HEV placentas were associated with stillborn infants, in contrast to only 22% (89/400) of control placentas. The difference in the proportion of still‐births was greatest when the gestational age was 25 weeks or greater. Other significant positive associations with HEV included the presence of meconium staining, intrauterine growth retardation, smaller placentas, and maternal hypertension or toxemia. Pathologic findings associated with HEV were chronic villitis, erythroblastosis, thrombosis and cord abnormalities. No association was found with infant Apgar score or fetal anomalies. The association of HEV with a high proportion of stillbirths in the registry suggests that further understanding of this lesion might shed light on the problem of unexplained stillbirths.

Family practice training over the first 26 years: a cross-sectional survey of graduates of the University of Washington Family Practice Residency Network.

Purpose To describe the current practice setting, scope of practice, and adequacy of residency training of a large cohort of family practice (FP) residency graduates. Method In February 2000, questionnaires containing 120 demographic, practice, and training items were mailed to 1,498 graduates (1973–1999) of the University of Washington Family Practice Residency Network. Results A total of 983 (71%) graduates completed the survey. Of the 870 who were currently practicing family physicians, 38% were women, 73% worked full-time, 45% practiced in FP groups, and 97% were board certified in FP. A total of 37% practiced in communities of fewer than 25,000 residents, and 29% practiced in federally designated health provider shortage sites. Most cared for their patients in the hospital: 79% for adult medical patients, 54% for adult ICU/CCU patients, and 71% for children. Most provided maternity care: 63% delivered babies and 58% assisted at cesarean sections (12% as primary surgeon). Even in cities of over 100,000, 58% delivered babies. Large numbers of responders performed colposcopy, flexible sigmoidoscopy, vasectomy, and minor surgery. A higher proportion of the most recent graduates provided maternity care and performed colposcopy. Most graduates reported that residency training prepared them well. Conclusions FP residency training is modeled to prepare primary care physicians to meet the needs of all patients in all communities. These data document the success of this model in producing and sustaining family physicians to fulfill these roles in practice.

Deciding about using hormone therapy for prevention of diseases of advanced age

The purpose of this study was to examine the decision processes in which women engage as they commit to use, and continue to use, postmenopausal hormone therapy and to consider the implications of these decision processes for health care. Data were collected from midlife women in a series of six focus groups encompassing multiple ethnic and social groups. Focus group transcripts were analyzed for themes reflecting components of womens decision processes and decision patterns, and points at which health care providers were involved were identified. Participants identified five phases of a decision process: precontemplation, contemplation, commitment, critical evaluation, and continuance of therapy. Health care providers have significant opportunities to interact with women during the transitions between these phases; hence these interactions need to be synchronized with womens decision processes and need to address affective as well as cognitive processes.

Satisfaction of Family Physicians Working in Community Health Centers

Background: Community health centers (CHCs) receive

Rewards and Challenges of Community Health Center Practice

2.9 billion in federal funding to provide primary care to 20 million people annually, and these numbers are increasing. Understanding of physician satisfaction in CHCs may help guide recruitment and retention efforts aimed at expanding CHC programs. The objective of this study was to contrast the satisfaction of family physicians working in CHCs with the satisfaction of family physicians working in other practice settings. Methods: Analysis of 4 cross-sectional surveys of recent residency graduates from the Washington, Wyoming, Alaska, Montana, and Idaho Family Medicine Residency Network. Surveys were conducted approximately every 3 years from 2000 to 2010. Main outcome measures included self-reported satisfaction with residency training, practice, and specialty on a 1 (low) to 5 (high) scale. Results: Eight hundred ninety-three family physician responded (response rate, 61%), of whom 129 were CHC physicians and 764 were non-CHC physicians. Compared with non-CHC physicians, higher proportions of CHC physicians reported being highly satisfied with their residency training (79% vs 61%; P < .01) and choice of specialty (74% vs 60%; P < .01). In contrast, lower proportions of CHC physicians were highly satisfied with their employers (62% vs 72%; P = .05). There were no differences in satisfaction with practice partners, income, practice location, or work hours. After adjustment for physician, practice, and community characteristics, CHC physicians were more likely to be highly satisfied with their residency training (odds ratio, 2.6; P = .001) and their choice of specialty (odds ratio, 1.7; P = .03). CHC physicians were less likely to be highly satisfied with their employers (odds ratio, 0.5; P < .01). Conclusions: The lower level of satisfaction reported by CHC physicians has implications for workforce recruitment and retention in CHC settings. In an era of CHC growth, efforts to improve physician relationships with employers may be a potential target for enhancing the physician workforce in CHCs.