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Background: The 1989 recommendations of the US Preventive Services Task Force (USPSTF) represent an emerging consensus about which clinical preventive services should be delivered. However, practicing physicians disagree with a number of the recommendations in the Task Force prevention guidelines, and the reasons for disagreement have not been widely explored., Methods: A survey questionnaire assessing physician agreement or disagreement with the USPSTF recommendations was sent to all 1784 active members of the Ohio Academy of Family Physicians in October 1990. A factor analysis was performed on the items with which at least 5% of physicians disagreed. Associations of physician demographics and attitudes with the factor scores were then examined., Results: At least 5% of the 898 responding physicians disagreed with 67 of 150 USPSTF recommendations. Physicians disagreed with the USPSTF recommendations in three ways: (1) they believed that screening for some cancers is appropriate, even though not recommended by the USPSTF; (2) they believed that screening for other diseases in some populations is appropriate, even though not recommended by the USPSTF; and (3) they disagreed with some USPSTF recommendations for screening that is considered time-consuming or intrusive. Further analyses showed that practice setting and experience with the USPSTF guidelines were predictive of all three disagreement factors. Physician age, race, residency training, and reasons for disagreement were associated with two of the three factors., Conclusions: Physician disagreement with the USPSTF recommendations was not random but clustered into three distinct factors. An opportunity exists to design educational interventions for targeted subgroups of physicians. The views of practicing physicians should be incorporated into future guidelines.

Family physicians play a significant role in the management of patients with diabetes. The classification of diabetes has been revised, requiring higher plasma glucose levels for diagnosis. Insulins have been purified, with contamination by proinsulin-like substances now routinely being less than 50 parts per million. As a result of increasing evidence that improved metabolic control is associated with a lower incidence of complications, especially for microvascular complications in patients with insulin-dependent diabetes, a variety of strategies have been developed to improve control. Early experience with frequent injections of insulins and constant infusion systems (pumps) has been favorable, though achievement of lower blood glucose levels is not without risk. Good control in pregnancy is especially critical. Glycosylated hemoglobin has proven to be a useful addition to assessing control. To achieve optimal therapeutic results, diabetes should be viewed as a chronic biomedical disease with major behavioral components.

In this report are examined the patterns of control of diabetes mellitus achieved by practicing family physicians in small communities in the Pacific Northwest and Alaska. The diabetic patients under study appear to be broadly similar to patients in tertiary care settings, where most studies of diabetes care have been carried out. Motivated, competent family physicians, knowledgeable about tight control of diabetes, appear to have considerable difficulty in maintaining even modest levels of biochemical control. Goals in this study for fasting plasma glucose levels for patients with insulin-dependent diabetes mellitus (IDDM) averaged between 120 and 160 mg/100 ml. Glucose levels actually achieved ranged up to 360 mg/100 ml. A similar though lesser discrepancy was noted for patients with non-insulin-dependent diabetes mellitus (NIDDM), with achieved levels ranging up to 270 mg/100 ml fasting plasma glucose. There were wide individual differences among physicians in management styles and treatment policy, including wide discrepancies in emphasis on diet, use of oral hypoglycemic agents, and insulin use. This diversity is felt to merit further investigation. Collaborative studies of this type with community based physicians are feasible and academically rewarding. Significant research questions can be addressed and answered.U

Increasing attention in the literature has focused on the relationship between psychosocial factors and infertility. This study presents a psychosocial profile of infertile couples over a two-year period. During this period, psychosocial data including life change, social support, and personality traits were obtained prospectively from 134 individuals participating in the In Vitro Fertilization Program of the Jones Institute of Reproductive Medicine at the Eastern Virginia Medical School. Instruments utilized included the Life Experiences Survey, the Family APGAR, the Friends APGAR, the Multidimensional Health Locus of Control, and the Eysenck Personality Inventory. Despite the presumed adverse psychological influence of their infertility, Life Experience Survey scores for both men and women did not differ significantly from normative data. Family APGAR scores indicated a high degree of satisfaction with family function. Friends APGAR scores were somewhat lower than normative data. The Multidimensional Health Locus of Control, a measure of perception regarding factors influencing health outcomes, was unremarkable. The Eysenck Personality Inventory revealed a lower score on the neuroticism scale for the men. These psychosocial results were surprisingly normal.

A number of benefits have been claimed for early ambulatory experience in the training of family physicians, although few practical examples have been reported. This paper describes an approach to the education of first and second year medical students interested in family medicine which places heavy emphasis on community-based ambulatory care. During the first year, an elective introductory preceptorship permits students to participate in the office practice of a family physician in a limited role. Seminars are offered concurrently to provide integrating principles and perspective. In the second year, a nine-month-long continuity clerkship is offered in which students gain intimate contact with a small panel of families and practice the skills of primary care in the offices of family physicians. Clinical experience is accompanied by weekly seminars and integrated with elements of the required curriculum. Selected evaluation data are presented, which attest to the achievement of course objectives and provide support for the claim that this approach is beneficial to students seeking careers in primary care.

This study examines the relationship between selected interview characteristics, particularly physicians' verbal behaviors, and levels of patient satisfaction and understanding. Twenty-nine initial patient interviews by 11 physicians at the University of Washington Hospital Family Medical Center were videotaped and rated using a modified Bales' technique. Questionnaires provided measures of patient satisfaction and understanding. Results of correlation analysis indicate that higher patient satisfaction was associated with greater interview length, increases in the proportional time spent by the physician in presenting information and discussing prevention, and shorter chart review times. Increased patient understanding was associated with increases in the proportional time spent presenting both information and opinions, close physical proximity, and reduced chart review time. Implications of the results are discussed as well as methodological issues relating to further research.

The questions of illness susceptibility and the how and why of the onset of illness are of great concern to family physicians, who are constantly presented with a bewildering array of maladies. This paper presents a model of illness onset as related to life change which is felt to be a highly relevant and useful concept for family physicians. This model has been developed over many years and proposes that illness onset is predictably related to life change, which in turn is a reflection of the amount of coping required. The specific development of these concepts is presented in detail including the development and quantitation of the social readjustment rating scale which quantifies life changes.

A ten-year experience with a continuity clerkship taught to second-year medical students is described. Students enrolled in this course spend one half-day per week for nine months with a practicing family physician, attend a weekly seminar or workshop, and write a longitudinal patient care report. This comprehensive report summarizes their experience with a patient or a family and addresses pertinent medical and psychosocial issues. Forty-four of these reports were analyzed for the 1981-82 academic year. The analysis revealed that the main benefits to the students from the longitudinal experience were (1) recognizing the importance of continuity of care, (2) observing the interplay between the social environment, family, and the patient's health, (3) gaining insight into the role of the family physician, and (4) experiencing the difficulties of chronic disease management.

This study demonstrates that there is a definite constancy to nonverbal behavioral interaction between patient and physician in a defined office interview setting. This work also introduces the technique of lag sequential analysis into family medicine research. Further refinements of study design and technique are needed in future studies to elucidate information that would be helpful to physicians in the management and care of patients and in patient education.

The interview portion of 34 patient-physician visits at a family medical center was videotaped. Videotapes were screened by two judges in two major nonverbal categories, immediacy and relaxation. Physician and patient were scored separately at 40-second intervals for 11 component parameters of the two major categories. These scores were correlated with patient satisfaction and understanding, ascertained by post-interview questionnaire. For analytical purposes, patients were assigned to low or high satisfaction groups and low or high understanding groups. Statistically significant (P less than or equal to 05) differences between low and high satisfaction groups were demonstrated with respect to overall physician immediacy; five individual physician nonverbal parameters; and two individual patient nonverbal parameters. Similar statistical results were obtained for understanding groups. This preliminary investigation suggests that nonverbal behavior of the physician in the patient-physician interview is important in determining patient satisfaction and understanding.