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In a family practice office with volume representative of an average one-person practice, the implementation of colposcopy services was studied. During six months, 257 patients received Papanicolaou (PAP) smears. These patients represented 16.2% of the total 1,585 female patient visits for ages greater than 16. Of the 257 cytology specimens, 10.1% (26) revealed dysplasia or evidence of Human Papilloma Virus (HPV), indicating the need for colposcopic examination. Pathology reports of all biopsied cases confirmed the presence of dysplasia or HPV. These results suggest that the average family physician might reasonably anticipate about 100 colposcopy sessions per year, assuming each patient receives a diagnostic and a therapeutic colposcopic evaluation. In the course of colposcopy services in a family practice, 46 patients underwent 67 colposcopic examinations with cervical biopsy and/or cryotherapy in the office. Some patients received nonsteroidal anti-inflammatory medication 30-60 minutes before the procedure, with selection according to physician preference. All patients rated the pain experienced during the procedure on a 10-point visual-analog scale. Pain scores were significantly lower in those who received medication. Overall, patients tolerated the procedure well and there were no reported complications. Because of the possibility of such factors as the placebo effect influencing these results, a randomized, placebo-controlled, double-blind study will be needed to verify the findings.

Bacterial contaimination of endoscopes can be clinically significant. While current data suggest that flexible sigmoidoscopy may entail fewer risks than upper endoscopy, these data are too incomplete to draw this conclusion. Careful cleaning and disinfection after each procedure are recommended. Gas sterilization of the endoscope and gas or heat sterilization of accessory equipment may be necessary in certain clinical situations. It must be remembered that hundreds of thousands of endoscopic procedures were performed in the 1970s using cleaning only without substantial health risk. The processes do not have to be complicated or difficult. Staff must be well trained and must understand the potential risks of working with disinfecting agents such as alkaline glutaraldehyde. It is recommended that the clinician fully understand the cleaning and disinfection steps and be able to perform them. It is important that office procedures be based on efficacy, not convenience. The procedures developed to date are not ideal and the ideal disinfectant has yet to be found. Cleaning and disinfecting machines have been developed, but they are expensive and their efficacy and safety are no better than hand-performed methods. An alternative approach to reducing transmission of infections by endoscopes may be to seek less adherent plastic substances for the endoscope sheath. The introduction of immersible endoscopes has helped with cleaning, but their use may also give rise to a false sense of security. Diligent attention to cleaning and disinfection is still necessary.(ABSTRACT TRUNCATED AT 250 WORDS)

Nasolaryngoscopy is easy to learn and safe and convenient to perform. It is readily accepted by patients and is a rich source of clinical information. The flexible nasolaryngoscope allows the physician to directly observe the anatomy of the nasal passages, pharynx and larynx. The procedure is helpful for identifying the etiology of chronic nasal complaints and hoarseness. Other possible indications for nasolaryngoscopy include suspected nasal foreign body, recurrent nasal or pharyngeal bleeding, and epiglottitis. With the use of this instrument, treatment of otolaryngologic conditions may be more specific, thereby reducing unnecessary referral or delay in treatment.

A case series is presented consisting of 210 symptomatic patients evaluated by family physicians using fiberoptic rhinolaryngoscopy. The case series is analyzed to evaluate patient tolerance of the procedure, to measure the time required for the procedure, and to explore the clustering of diagnostic findings as they relate to presenting symptoms. Family physicians performed the examinations in an average of 4.4 minutes, with a median discomfort score of 2 on a scale of 0 to 10. A change in the diagnostic assessment or management plan following examination occurred in 90% of cases. Laryngeal pathology was identified in 73% of patients with chronic hoarseness, 60% of patients with both chronic hoarseness and nasal symptoms, and 3% of patients complaining of chronic nasal symptoms only. Nasal polyps or purulent drainage from the sinus ostia were found in 28% of patients with chronic nasal symptoms, 30% of patients with both chronic hoarseness and nasal symptoms, and 2% of patients with chronic hoarseness only. Incomplete examination (because of gagging) occurred in only 1 of 210 cases. This study demonstrated high diagnostic yield, rapid acquisition of technical skill, minimal patient discomfort, significant impact on diagnosis and management, and minimal time required for examination.

This is the first multisite report of esophagogastroduodenoscopies (EGDs) performed by family physicians. The first 717 EGDs performed by family physicians from 8 separate office practices provide a practical and safe rationale for selected cognitive and psychomotor aspects of continuing medical education after residency training. Although primarily in private practice, these physicians were affiliated with 6 academic institutions. This group of family physicians received training in short courses. The average amount of hands-on training before independent EGD was 8 supervised cases. Cumulatively, these data represent 227 months (18.9 years) of office practice. All cases were collected sequentially from the beginning of each physician's experience, and 454 cases were collected prospectively. Physicians reported excellent patient tolerance. Diagnostic yields were high, and biopsies were performed where appropriate. Pathologists reviewed biopsy specimens from 213 sites. The family physician endoscopic diagnosis agreed with the tissue diagnosis in 188 cases (88 percent). Physicians believed that EGD enhanced management or changed the diagnosis in more than 89 percent of cases. One bleeding complication requiring overnight hospitalization was noted. This complication rate 0.0014 (1/717) compares favorably with published subspecialty complication rates 0.0013 (1.3/1000). These data confirm the ability of some family physicians to perform EGD and suggest that continuation is safe. Biopsy analysis indicates diagnostic accuracy is high. Further study on the cognitive aspects and the defragmentation of care is needed.

A randomized prospective study examined the impact of bowel gas introduced by 65-cm flexible sigmoidoscopy (FS) on the ability to perform air-contrast barium enema (ACBE) on the same day. Seventy-five patients at risk for colorectal cancer were randomly assigned to two groups. Of these, 28 patients in each group completed the protocol. The study group received flexible sigmoidoscopy and air-contrast barium enema on the same day, whereas the control group had their air-contrast barium enema on a different day. Bowel gas observed on an abdominal scout film prior to air-contrast barium enema was quantified on a scale of 1 (excessive gas) to 5 (no gas). The cancellation rate for the air-contrast barium enema was measured in each of the groups. The study group had significantly more bowel gas compared with the control group (p = 0.000003). The air-contrast barium enema cancellation rate was also higher in the study group (36%) than in the control group (14%) (p = 0.06). Greater than 60% of the study group patients were successfully examined. Same-day scheduling would reduce the number of bowel preparations required in the evaluation of patients at risk for colorectal cancer. Although retrospective studies have suggested no impact of same-day FS on ACBE quality, radiologists in this study canceled approximately one-third of scheduled patients due to perceived excessive bowel gas.

The 1982 US Festival, a three-day outdoor rock music festival, attracted close to 410,000 people. Through a private contractor, a group of physicians participated in the design, administration, and implementation of medical care for this event. Basic ambulatory care was provided by a multitiered approach, using emergency medical technicians, registered nurses, medical health counselors, and physicians. A total of 2,623 encounters required examination and evaluation by health professionals. Thirty-eight percent (1,014 cases) involved minor surgical trauma. Extreme environmental conditions, including temperatures exceeding 114 F, high winds, and unusually high dust concentrations, were thought to be responsible for 361 (13.6%) cases of reactive airway disease and 184 (7%) cases of heat exhaustion. There were 91 transports, of which 12 were classified as major casualties; there were no deaths.

The UCLA Family Practice Residency continues to use 60-cm flexible sigmoidoscopy in the care of patients. Between July 1980 and June 1983, 450 patients received an examination with the 60-cm flexible sigmoidoscope. One or more adenomatous polyps were detected in 21 patients. Adenocarcinoma was found in five patients. Four patients were found to have a villous adenoma, and four patients were determined to have inflammatory bowel disease. Of the 34 discrete lesions, 32 percent, 41 percent, and 27 percent were located between 0 and 20 cm, 21 and 35 cm, and 36 and 60 cm, respectively, from the anus. No complications were encountered. Sixty-four percent of the examinations were done by a family practice resident supervised by a full-time faculty member. The remaining 36 percent of the examinations were performed by full-time faculty. The overall detection rate for significant pathology was 8.0 percent. Most pathology by far was found in symptomatic patients. These results validate the safety and viability of 60-cm flexible sigmoidoscopy when performed by properly trained family physicians and family practice residents-in-training.

A three-year prospective chart audit of a family practice residency program was performed to measure physician compliance in following the recommendations of an adult immunization program. Despite curriculum changes, performance self-evaluation, and reminders by faculty members to residents about the need for adult immunization, physician compliance was poor in the second year of the study. It was thought that components of the medical record might be improved to facilitate physician compliance in the adult immunization program. At the beginning of the third year of the audit, tetanus and pneumococcal vaccines were preprinted on the health maintenance inventory (HMI), but influenza was not. The chart design also was changed to put the HMI in a more prominent place. In the third year of the audit, physician compliance with tetanus and pneumococcus immunization improved significantly. The results of the chart review suggest that physician compliance with adult immunization programs can be improved with appropriate chart design.

In comparison with the rigid sigmoidoscope, the flexible instrument has certain advantages that enhance its value in the office setting. This article describes one institution's success with the flexible scope in outpatient examinations and the proper technique for its use.

The rising incidence of pelvic inflammatory disease (PID), coupled with the development of more sophisticated and effective diagnostic techniques, has created a new body of knowledge regarding the microbiology, diagnosis, and natural history of this disease. Acute pelvic inflammatory disease is the major gynecologic health problem in the United States. Distinguishing acute PID from the other causes of acute pelvic pain is often a difficult task. Careful consideration of a patient's risk profile for PID and utilization of the diagnostic techniques available are invaluable in helping the clinician accurately make this differentiation. The microbial spectrum involved in PID is complex and must be taken into consideration when selecting an antibiotic regimen. The recent addition of new, broad-spectrum antibiotics to the physician's therapeutic armamentarium has led to increasingly effective management options. Despite the effectiveness of current medical and surgical therapy, the staggering economic, medical, and social consequences of PID mandates more aggressive efforts at its prevention.

A new method for the detection of fecal occult blood was tested in a clinical setting. The test is performed by placing a chemically treated paper pad in the toilet bowl after a bowel movement and observing for color change on the pad. This method eliminates the mechanical task of handling or gathering stool by the patient. Forty-four valid trials were completed in 19 patients with known risk factors for gastrointestinal disease. A widely used reference standard (Hemoccult II) was utilized as a control method against which the study method was compared. Concordance of the results of the study method was noted in 95.8 percent of positive cases and 100 percent of negative cases. This preliminary study supports further investigation. If the aesthetic aspects of fecal occult blood testing can be improved, there may be improvements in patient compliance with screening protocols for the early detection of colorectal cancer.

Termination of pregnancy by means of "menstrual extraction" is a useful procedure for family physicians opting to offer this service to their patients. It is an easily performed procedure which, when compared to the presently available avenues for abortion, offers significant advantages in cost, diminished morbidity, and the opportunity for continuity of care by the primary physician. The procedure is successful in properly selected patients 99 percent of the time.

Medical students frequently have questions about the specialty of family practice. Responses to 30 questions commonly asked about family practice are presented with a review of recent literature. These responses may assist medical students and their advisors in considering the choice of family practice as a career.

The asymptomatic carotid bruit is not an uncommon finding in patients aged 45 years and older. The presence of such a finding has been associated with an increased incidence of stroke and cardiovascular death. The optimal evaluation and management of such patients are still unresolved. Noninvasive carotid evaluation appears to be useful for defining the degree of carotid artery stenosis and possibly in identifying a particular subset of patients at high risk for stroke. Whether patients with asymptomatic carotid bruits are best managed medically or surgically remains controversial and will require further investigation.

'Social drugs' such as nicotine, alcohol and caffeine may be risk factors in a variety of disorders. Over a five-year period an audit of 954 medical records was carried out in a university-based family medicine training programme. The aim was to investigate ways of improving physicians' compliance with the recording in the data base of the consumption of these substances by patients. Instruction through lectures and reminders produced no change in the recording of social drug usage in year 2, but the distribution of model dictations led to a significant change in year 3 for the recording of nicotine and alcohol consumption. This effect was sustained in years 4 and 5. Visual cues in the medical record led to a significant improvement in the notation of caffeine usage in year 4 and the effect was sustained in year 5. Additional audit sessions did not increase compliance with caffeine notation. Faculty and resident compliance with the recording of social drug history were not significantly different.

Ectopic pregnancy continues to be a major clinical problem and is the leading cause of death in the first trimester of pregnancy. Diagnosis can be elusive. A thorough knowledge of the clinical spectrum of this disease, as well as the diagnostic tools available to the primary care clinician, provides the opportunity for making an early diagnosis. This is essential if the morbidity and mortality of ectopic pregnancy are to be reduced.

Patient satisfaction with resident physicians and patient satisfaction with faculty physicians was investigated in three clinical centers of a county hospital-based family medicine residency. Only patients in a continuity relationship (minimum 5 visits) were studied. Utilizing a previously validated Patient Satisfaction Questionnaire (PSQ), the dimensions of access, availability, continuity, finances, physician humaneness, and physician quality/competence were measured. Although there was little discriminant power between the measures of physician humaneness and quality/competence of care, overall internal validity was high. Availability and finances created the most dissatisfaction. Residents' care was reported to be as satisfying as that delivered by faculty physicians. Differentiation between system dependent factors and physician-dependent factors may be difficult among patients with a demonstrated continuity relationship. Nevertheless this study demonstrated a high internal validity for the short form of the PSQ in yet another practice setting. This instrument is available for further investigation in clinical settings.

Sixty-three consecutive fourth-year medical students applying for a family medicine training programme based in a county hospital questioned about their anticipated practice style and the projected cost of malpractice insurance premiums during their first year of practice. Those who felt committed to providing obstetric services within their family practice estimated a much lower first-year dollar cost for malpractice insurance than those who were not committed to obstetric services. The difference in estimates was greater than $10 000 per year. Both groups far exceeded the actual quoted first year cost by three separate malpractice insurance companies. This study suggests that medical students may be influenced by unrealistic estimates of malpractice insurance costs prior to real world experiences. Furthermore, these estimates may indicate widespread ignorance and/or misinformation among medical students considering a family medicine career. malpractice suits and the fear of them remain, however, an important distraction from the provision of patient care services in the United States.

Schirmer's test is a simple, semiquantitative test of tear production. It is based on the physical tendency of a fluid to travel along a strip of porous material by capillary action due to surface tension. Sterile strips, standardized and prepackaged, are available from local scientific supply houses. The low cost and simplicity of this test make it useful in confirming the diagnosis of diseases involving decreased lacrimal secretion.

The authors discuss ways to increase the funding base of a family medicine residency program through the appropriate use of procedures related to patient care and the provisions of service. Following a commitment of cooperation by residents and faculty members, certain principles of a business practice management curriculum were expanded and applied to a residency program. A written procedure manual describing the intricacies of the fee-for-service system was prepared for interns. Mechanisms for the review of patient care productivity and educationally productive incentives were developed. All of these steps were helpful in achieving improvement in the funding base for the residency. Areas for potential expansion in training programs and financial and staffing strategies to increase revenues are discussed. Although administrative decisions regarding fees and collection mechanisms are mentioned, this discussion focuses on educational and patient care activities that also produce revenue.

Human insulin may be advantageous for certain subsets of patients, such as those with gestational diabetes and those who need insulin only during stress or surgery. To date, there is no evidence to support the use of human insulin in diabetics who are doing well on older insulin preparations.

Flexible sigmoidoscopy became available in 1976. To date, studies comparing it with rigid sigmoidoscopy support an increase of 2.5 to six times in the flexible sigmoidoscope's ability to detect polyps, and a two- to threefold increase in detection of colonic neoplasms in the same patients. This paper summarizes the current reported results of flexible sigmoidoscopy to date and describes the instrument and procedure as done at the UCLA Family Practice Residency Program. The flexible sigmoidoscope deserves evaluation for widespread primary care application.

This is a study of interhospital patient transfers to a medium-sized county sponsored hospital. During the three-month period studied, there were 416 patients who met the study criteria. Thirty-eight (9%) of the patients were transferred because the county hospital offered a higher level of medical care or medical services not available at the presenting facility, while the remaining 378 (91%) were transferred because of their health insurance status. Two hundred and ninety-six patients (71%) had no medical insurance of any kind, 117 (28%) had government sponsored health insurance, and three (1%) had private insurance. Of these transferred patients, 32 (8%) arrived in a medically unstable condition and one patient died shortly after suffering a respiratory arrest en route. It is concluded that interhospital transfer of underinsured or uninsured patients may represent a significant risk to patients.

Acne vulgaris is a common skin disorder that is socially disabling to some degree in the majority of adolescents. Effective management of this disease has two major components: a strong physician-patient relationship and a sound medical regimen. The former is necessary to foster patient compliance with the long-term therapeutic regimen required, as well as to reduce the disease's potential for emotional scarring. The rational usage of the various topical and systemic medications available will serve to decrease the frequency and severity of exacerbations as well as to minimize possible scarring. Specific recommendations as to moisturizers and cosmetics are included.

This study reports costs incurred over a nine-and-one-half-month period following the introduction of obstetrical ultrasound into a group family practice serving primarily prepaid health plan patients. During this introductory period, 248 examinations were performed by family physicians and refereed by a radiologist for accuracy. The estimated cost to the practice was $95 per examination. This figure includes physician training expenses, professional fees, personnel, equipment and maintenance costs, costs for exams repeated due to technical error, and costs for additional consultation by a radiologist. Previously, all exams were referred to other consultants, and the charge was $185 per exam. Thus, in-office ultrasound exams performed by family physicians can provide cost savings while maintaining high standards of obstetric care.

First-year residents in two affiliated Southern California three-year family practice residency programs were studied prospectively. Those who chose to leave their program following completion of the first year were compared to those who stayed for the second year of residency on the basis of stress and personality factors. Results indicate that those who left their programs were more impulsive at baseline measures and increased their self-discipline during the year, while those who stayed were more self-disciplined at baseline and increased their impulsiveness during the year. Those who left were more socially active at the end of the year than those who stayed, and they experienced a significantly greater increase in acute anxiety by the end of the year.