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Journal issue focuses on competing demands, patient encounters, and delivery of preventive care in family practice

Family physicians provide both acute and preventive care to families. The patients they see often have overriding emotional concerns, exert pressure for antibiotics they don't need, and sometimes have needs that take priority over preventive care services such as smoking cessation counseling. They also treat patients who visit them repeatedly and thus present their own set of challenges. Finally, characteristics of the practice organization itself and the family doctor's own personal style have an impact on the treatment provided to patients.

All of these issues were addressed by the landmark Prevention and Competing Demands in Primary Care (P&CD) Study of 18 Nebraska family practices, which was led by Benjamin Crabtree, Ph.D., of the University of Medicine and Dentistry of New Jersey. Six P&CD studies, supported in part by the Agency for Healthcare Research and Quality, were published in the October 2001 Journal of Family Practice. These studies, including an overview of the P&CD Study, are briefly described here.

Crabtree, B.F., Miller, W.L., and Stange, K.C. (2001, October). "Understanding practice from the ground up" (HS08776). Journal of Family Practice 50(10), pp. 881-887.

The goal of the P&CD Study was to gain a thorough understanding of family practices. The researchers examined 18 practices drawn from a random sample of Nebraska family practices and studied them intensively over a 4- to 12-week period. Field researchers directly observed the practice environment and clinical encounters, conducted formal and informal interviews with clinicians and staff, had patients fill out "exit cards," and reviewed medical records.

They examined the organizational contexts that support preventive care services, identified competing demands imposed by carrying out prevention and illness care during clinical encounters and in practice, compared approaches used by practices with high versus low intensity of preventive services delivered to eligible patients, and analyzed methods used to deliver different types of preventive services. This approach provided insights into a wide range of practice activities, which were later integrated into the data collection protocol. The researchers also initiated practice meetings with participating clinicians to provide feedback, resulting in a more collaborative practice change.

Finally, they examined characteristics of the surrounding community and larger health system, such as expectations of the local hospital systems, by interviewing regional managers and medical directors. This collaborative model of practice-based research provided insights into family care practices from multiple perspectives: clinician, patient, encounter, practice, community, and health system.

Scott, J.G., Cohen, D., DiCicco-Bloom, B., Orzano, A.J., and others. (2001, October). "Antibiotic use in acute respiratory infections and the ways patients pressure physicians for a prescription" (HS08776 and HS09788). Journal of Family Practice 50(10), pp. 853-858.

The most common problems seen by family doctors are acute respiratory tract (ART) infections, such as the common cold, bronchitis, pharyngitis, sinusitis, and ear infections. These illnesses usually are caused by viruses that do not respond to antibiotics and not bacteria, which do respond to antibiotic treatment. The inappropriate use of antibiotics for viral illnesses has led to the development of antibiotic-resistant bacteria, which has become a major public health problem. Yet patients still try to persuade doctors to inappropriately prescribe antibiotics. Family doctors participating in the P&CD Study were no exception. Their patients clearly used a variety of behaviors to pressure them into prescribing antibiotics for ART infections that did not warrant them.

Doctors should educate patients about the dangers and limited benefits of antibiotic use for most ART infections, and they should consider appropriate responses to patient pressures to prescribe antibiotics, suggest these researchers. They found that antibiotics were prescribed in 68 percent of visits for ART infection studied, and of those, 80 percent were determined to be unnecessary according to Centers for Disease Control and Prevention guidelines.

Patient pressure for antibiotics came in several forms, which the researchers identified as: direct request; candidate diagnosis (diagnosis suggested by the patient, for example, "I think I've got strep throat"), implied candidate diagnosis (recounting a set of symptoms specifically indexing a particular diagnosis), portraying severity of illness (inability to shake the illness); appealing to life-world circumstances (for example, the need to feel well for an upcoming family vacation); and previous successful use of antibiotics for the same problem. In cases in which antibiotics were clearly unnecessary, doctors often rationalized their prescribing practices by finding symptoms or assigning diagnoses to justify antibiotic use in order to satisfy the patient.

Jaen, C.R., McIlvain, H., Pol, L., and others. (2001, October). "Tailoring tobacco counseling to the competing demands in the clinical encounter" (HS08776). Journal of Family Practice 50(10), pp. 859-863.

Clinical practice guidelines that recommend smoking cessation counseling at every visit are unrealistic, since one in four visits by patients who smoke have competing priorities that reasonably override such counseling, according to these authors. On the other hand, tobacco cessation counseling occurred in only one-third of visits with patients who smoked, underscoring the need for tobacco cessation counseling to be reliably integrated into visits with smokers when competing demands are not present. Visits for well care and tobacco-related illnesses represent teachable moments that should not be missed, conclude the researchers.

They directly observed 91 outpatient visits by cigarette smokers visiting 20 family doctors in 7 Nebraska family practices as part of the P&CD Study to examine patterns and quality of tobacco counseling. In nearly half of the visits, doctors either followed recommendations, offering brief interventions based on the patient's willingness to quit (21 percent) or had to forego tobacco counseling due to competing patient priorities (for example, relief of acute pain, patient psychological distress, or complex medical concerns).

In the other encounters, tobacco cessation counseling fell short of recommendations, including visits among patients being seen for acute respiratory illnesses or other chronic conditions related to or worsened by smoking (22 percent of visits) and visits for illness unrelated to smoking where competing demands were low (27 percent of visits). This counseling failure often occurred despite the presence of a reminder system that identified the patient as a smoker.

Smucker, D.R., Zoink, T., Susman, J.L., and Crabtree, B.F. (2001, October). "A framework for understanding visits by frequent attenders in family practice" (HS08776). Journal of Family Practice 50(10), pp. 847-852.

Every family doctor has a few patients whom they see often and not necessarily for valid medical complaints. It seems that these "frequent attenders" are always in their office for something. These investigators compared clinical encounters of non-pregnant adults who were in the top 5 percent for visit frequency with age- and sex-matched non-frequent attenders at the 18 Nebraska family practices in the P&CD Study. Overall, visits by non-frequent attenders included less psychosocial complexity and dissonance compared with visits by frequent attenders. The majority of visits by non-frequent attenders (87 percent) were classified as biomedical.

Visits with the 62 frequent-attenders, who had made at least 25 visits in the previous 2 years, fell into the following types: simple medical (for example, simple acute foot injury), ritual visit for ongoing care (for example, injections for chronic low back pain), complicated medical, the tango (doctor and patient negotiate on medical solutions to multiple problems), simple frustration (for example, trying to get an appointment for a procedure scheduled quickly), psychosocial disconnect (the patient simply doesn't get the medical advice the doctor is conveying and doesn't plan to follow it), medical disharmony (patient is confused about the doctor's plan and is not sure it will help the current problem), and the "heartsink" visit (patient has multiple problems, but is not satisfied with anything the doctor proposes; the emotionally taxed doctor gets little satisfaction and much grief in return).

Frequent attenders were more likely to be older, divorced or widowed, in lower socioeconomic groups, and to have multiple physical and psychosocial ills and vague physical symptoms with no obvious etiology. Many frequent attenders seemed to have developed an intricate and harmonious relationship with the doctor and the office staff and nurses in the practice. Their visits often included friendly chatting and humor among patients, staff, and doctors.

Miller, W.L., McDaniel, R.B., Crabtree, B.F., and Stange, K.C. (2001, October). "Practice jazz: Understanding variation in family practices using complexity science" (HS08776), Journal of Family Practice 50(10), pp. 872-878.

Family physicians are told to implement guidelines, diagnose and treat patients in specific ways, and eliminate inappropriate variation in practice. However, these authors disagree with the conventional view that the best way to improve care is to eliminate variation. They view family practices as systems that self-organize, reveal emergent behavior, and co-evolve. Successful practices are ones that minimize errors, make good sense of what is happening, and effectively improvise to make good "practice jazz."

Inflexible standardization is often poorly responsive to the needs of different practices' diverse agents (clinicians, patients, and office staff) and to the almost constant situations of uncertainty, contextual uniqueness, and surprise that occur in practices, assert these researchers. They encourage all family practice staff members to become knowledgeable about practice guidelines and evidence-based practice and use the core skills they gain to implement flexible, locally meaningful systems to reduce medical errors.

The researchers also suggest that efforts to change and enhance family practice be focused on improving care as a whole and on developing the skills of relationship-centered care. They encourage policymakers to acknowledge the potential benefits of some kinds of practice variation and to supports its healthy evolution. Their conclusions are based on lengthy observations of 18 Nebraska family practices, which demonstrated that some practice variations are appropriate.

Robinson, W.D., Prest, L.A., Susman, J.L., and others (2001, October). "Technician, friend, detective, and healer: Family physicians' responses to emotional distress" (HS08776). Journal of Family Practice 50 (10), pp. 864-870.

With more than two-thirds of mental health disorders treated in primary care, it is not surprising that family doctors find themselves responding to patients' emotional distress on a daily basis. This study of the daily interactions of family doctors at 18 family practices participating in the P&CD Study revealed that doctors tended to respond to patients' emotional problems by using one of four approaches based on their personal philosophy (biomedical vs. holistic) and skill level (basic vs. more advanced). Depending on their approach, the doctors tended to fit four distinct profiles: technician, friend, detective, or healer.

The technician was medically oriented, dispensing medications and direct advice. Encounters were problem-focused, and at times the doctor appeared to be abrupt, ignorant of clear emotional distress, and not patient-centered. The friend was a biopsychosocially oriented doctor with basic skills, who typically explored patients' backgrounds, concerns, and spiritual dimensions of illness in a patient-centered fashion and often gave advice. The detective was usually biomedically focused, but when the occasion warranted, had a range of detective skills that allowed him or her to quickly sense patient cues of emotional distress that shed light on the patient's condition. The healer used a full breadth of biopsychosocial skills, integrated most aspects of care seamlessly, and appeared comfortable with both strictly biomedical and psychosocial dimensions of care.

Family doctors applied a wide range of skills differently with different patients in different situations. Yet most doctors appeared to have a preferred practice philosophy and singular skill-set that they regularly used during patient visits. These findings can help doctors identify their own style and consider ways of meeting particular patient needs that may be better suited to an alternative approach.

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