Valerie Gilchrist

Discussing Spirituality With Patients: A Rational and Ethical Approach

BACKGROUND This study was undertaken to determine when patients feel that physician inquiry about spirituality or religious beliefs is appropriate, reasons why they want their physicians to know about their spiritual beliefs, and what they want physicians to do with this information. METHODS Trained research assistants administered a questionnaire to a convenience sample of consenting patients and accompanying adults in the waiting rooms of 4 family practice residency training sites and 1 private group practice in northeastern Ohio. Demographic information, the SF-12 Health Survey, and participant ratings of appropriate situations, reasons, and expectations for physician discussions of spirituality or religious beliefs were obtained. RESULTS Of 1,413 adults who were asked to respond, 921 completed questionnaires, and 492 refused (response rate = 65%). Eighty-three percent of respondents wanted physicians to ask about spiritual beliefs in at least some circumstances. The most acceptable scenarios for spiritual discussion were life-threatening illnesses (77%), serious medical conditions (74%) and loss of loved ones (70%). Among those who wanted to discuss spirituality, the most important reason for discussion was desire for physician-patient understanding (87%). Patients believed that information concerning their spiritual beliefs would affect physicians’ ability to encourage realistic hope (67%), give medical advice (66%), and change medical treatment (62%). CONCLUSIONS This study helps clarify the nature of patient preferences for spiritual discussion with physicians.

A comparison of the National Ambulatory Medical Care Survey (NAMCS) measurement approach with direct observation of outpatient visits.

BackgroundThe National Ambulatory Medical Care Survey (NAMCS) informs a wide range of important policy and clinical decisions by providing nationally representative data about outpatient practice. However, the validity of the NAMCS methods has not been compared with a reference standard. MethodsOffice visits of 549 patients visiting 30 family physicians in Northeastern Ohio were observed by trained research nurses. Visit content measured by direct observation was compared with data reported by physicians using the 1993 NAMCS form. ResultsOutpatient visit physician reports of procedures and examinations using the NAMCS method showed generally good concordance with direct observation measures, with kappas ranging from 0.39 for ordering a chest x-ray to 0.86 for performance of Pap smears. Concordance was generally lower for health behavior counseling, with kappas ranging from 0.21 for alcohol counseling to 0.60 for smoking cessation advice. The NAMCS form had high specificity (range, 0.90–0.99) but variable (range, 0.12–.84) sensitivity compared with direct observation, with the lowest sensitivities for health behavior counseling. The NAMCS physician report method overestimated visit duration in comparison with direct observation (16.5 vs. 12.8 minutes). ConclusionsCompared with direct observation of outpatient visits, the NAMCS physician report method is more accurate for procedures and examinations than for health behavior counseling. Underreporting of behavioral counseling and overreporting of visit duration should lead to caution in interpreting findings based on these variables.

Physician and patient gender concordance and the delivery of comprehensive clinical preventive services.

Background:Understanding the role of patient- and physician-gender on delivery of preventive services has important implications for identifying strategies to increase preventive service delivery. We attempt to overcome methodological limitations of previous studies in examining the association of the patient–physician gender interaction on the delivery of preventive screening, counseling, and immunization services. Methods:In this cross-sectional study, research nurses directly observed 3256 consecutive adult patient visits to 138 family physicians. Delivery of gender neutral US Preventive Services Task Force (USPSTF) recommended screening, health behavior counseling, and immunization services was assessed by direct observation and medical record review. Multilevel regression analyses were used to test the interaction effect of physician and patient gender with preventive service delivery, controlling for patient age, insurance type, number of office visits in the past 2 years and physician age. Results:The interaction effect of physician and patient gender was not significantly associated with delivery of gender neutral screening, counseling, or immunizations. Patients of female physicians were more up-to-date on counseling services (P < 0.01) and immunizations (P < 0.05) than patients of male physicians. Male patients, independent of physician gender, were more up-to-date on counseling and immunizations (P < 0.01). Conclusions:Physician-patient gender concordance is not associated with delivery of more preventive services. Rather, female physicians provide more counseling and immunization services to all of their patients. Previous research showing higher rates of gender-specific screening achieved by women physicians may have been an indication of an overall greater prevention orientation among women physicians rather than a specific benefit of gender concordance.

Physician Activities During Time Out of the Examination Room

PURPOSE Comprehensive medical care requires direct physician-patient contact, other office-based medical activities, and medical care outside of the office. This study was a systematic investigation of family physician office-based activities outside of the examination room. METHODS In the summer of 2000, 6 medical students directly observed and recorded the office-based activities of 27 northeastern Ohio community-based family physicians during 1 practice day. A checklist was used to record physician activity every 20 seconds outside of the examination room. Observation excluded medical care provided at other sites. Physicians were also asked to estimate how they spent their time on average and on the observed day. RESULTS The average office day was 8 hours 8 minutes. On average, 20.1 patients were seen and physicians spent 17.5 minutes per patient in direct contact time. Office-based time outside of the examination room averaged 3 hours 8 minutes or 39% of the office practice day; 61% of that time was spent in activities related to medical care. Charting (32.9 minutes per day) and dictating (23.4 minutes per day) were the most common medical activities. Physicians overestimated the time they spent in direct patient care and medical activities. None of the participating practices had electronic medical records. CONCLUSIONS If office-based, medically related activities were averaged over the number of patients seen in the office that day, the average office visit time per patient would increase by 7 minutes (40%). Care delivery extends beyond direct patient contact. Models of health care delivery need to recognize this component of care.

Handheld computer use in a family medicine clerkship.

Purpose The objectives of this study were to track students’ use of medical and nonmedical personal digital assistant (PDA) software and to obtain students’ ratings of the usefulness of PDAs in a family medicine clerkship. Method During the academic year 2001–02, third-year clerkship students at the Northeastern Ohio Universities College of Medicine were loaned PDAs equipped with company-installed software, such as a date book and address book. Additional software was installed (Griffiths 5 Minute Clinical Consult®, ePocrates qRx®, ePocrates qID®, iSilo®, HanDBase®, MedCalc®, and Application Usage®). Pre- and postorientation questionnaires and a post-rotation evaluation measured students’ comfort level, the perceived usefulness, and ratings of programs on their PDA. Application Usage tracked the number of minutes and times students used each software program. Results Eighty-five students completed the study. They rated ePocrates qRx and Griffiths 5 Minute Clinical Consult the most useful medical software programs. PDAs were rated as “almost always” enhancing the clerkship experience. Students reported the PDA altered the way they accessed clinical information and that every few days it helped them understand a clinical discussion. Experience with computer technology was correlated with PDA use. Conclusions This study objectively demonstrates clerkship students’ use of PDA resources. Students’ use mirrors their assessment of the value of the software. Although PDAs and software programs can be an expense, it is a worthwhile educational resource as evaluated by the medical student.

Recognition and management of obesity in a family practice setting.

Background: Research on the diagnosis and management of obesity in primary cure is limited. Our study goals were to describe the rate of obesity in a primary care setting, to identify factors associated with clinically recognized obesity, and to ascertain the level of diet and exercise counseling for obesity. Methods: Medical records from a private group practice were used for a historical cohort study of 276 patients (aged 40 years and older) who were provided care for a maximum 4.5-year follow-up period. Results: forty-six percent of the study patients (95 percent confidence interval = 0.43, 0.49) received an obesity diagnosis according to medical record notations. The diagnosis of obesity, in turn, was predicted by body mass index (BMI) quartile (P < 0.001) and a positive family history of cardiovascular disease (P < 0.01). Those patients with a diagnosis of obesity had a higher mean level of subsequent weight and diet counseling (P = 0.0001) but the same level (P = 0.11) of exercise counseling as nonobese patients. Weight and diet counseling was also predicted by diabetes (P = 0.0001) and hypercholesterolemia (P = 0.0003). Conclusions: The clinical recognition of obesity was not determined by BMI alone. Although weight and diet counseling was initiated for those individuals described as obese, there was a relatively low level of exercise counseling among these patients. Additional research could provide ways of reducing both physician and patient barriers to exercise counseling.

A sexual history-taking curriculum for second year medical students

The purpose of this study is to describe the evaluation of a sexual history-taking curriculum and correlates of student performance during a Clinical Skills Assessment. Reading assignments, small group discussions, a Saturday Sex workshop and performance on a Clinical Skills Assessment were evaluated. Students most favorably rated the workshop and least favorably rated the reading assignments. Eighty-four percent of students asked at least one sexual history question on the Clinical Skills Assessment. We were unable to identify any independent predictors of sexual history-taking behavior.

WHERE WE’VE BEEN & WHERE WE WANT TO GO: ADFM’S 40TH BIRTHDAY MEETING

ADFM celebrated its 40th “Birthday” at our annual Winter meeting in Washington, DC with champagne, cake, singing and dancing, the return of 20 former members to help us reminisce, and reflection on where we have been and where we should be going. As incoming President Kevin Grumbach, MD,

ADFM IS TURNING 40

The Association of Departments of Family Medicine (ADFM) is turning 40 next year! Founded in April 1978 with Paul Young, MD, as the first ADFM President, ADFM’s founding vision was to organize departments of family medicine to lead transformation of medical education, research, and health care to

From the Association of Departments of Family Medicine: PARTNERING FOR TRANSFORMATION: A MENU OF MANY POINTS OF ENTRY FOR YOUR DEPARTMENT

Healthcare delivery transformation is happening at many different levels but these myriad activities all share one thing in common: they are impacted heavily by the old adage, “all politics are local.” Recognizing that there are many points of entry to transformation, at many different system levels, the ADFM Healthcare Delivery Transformation Committee (HCDT) developed a graphic (Figure 1) to help understand how to engage with this healthcare delivery transformation process depending on the local context. Figure 1 Departmental points of entry. The graphic illustrates where the health system and community/population health interact and where within this overlap individual patient care takes place. This illustration is based loosely on a model put forth by the World Health Organization as a framework for people-centered integrated health services delivery.1 In addition to showing how elements of care models overlap, the graphic lists a series of resources for each component of the illustration, providing a literal menu to those interested in finding ways to partner for transformation. For example, leaders of a Department of Family Medicine may be interested in considering ways to partner with community or population health entities in their local environment and could look at the “Practical Playbook” for some examples of other systems and institutions that have successfully partnered with local community and public health organizations. ADFM’s HCDT Committee updates this menu of resources periodically; the color version of the graphic with the menu of resources hyperlinked for easy access is available at: http://www.adfm.org/Members/PrimaryCareCommunicationToolkit. The complexity of healthcare system change leads us to be like the proverbial “blind man and the elephant” in that we sometimes can identify the part we are dealing with, but are not as successful in recognizing the larger “beast.” The graphic is designed to help with this challenge. Chairs, Administrators, Division Chiefs and other senior leaders in Departments of Family Medicine are best positioned to understand the local politics and to guide Departments in selecting entry points that will likely have the greatest impact and intended outcome. We will continue to evolve this graphic through our work over the year to help Departments of Family Medicine and other organizations understand how they can partner and envision a different future within their own local reality.