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Likely yes. Point-of-care ultrasound (POCUS) screening for abdominal aortic aneurysm (AAA) by nonradiologist physicians is 98% sensitive and 99% specific, compared with imaging performed by radiologists (strength of recommendation [SOR]: B, meta-analysis of diagnostic accuracy studies mostly involving emergency medicine physicians). European family physicians demonstrated 100% concordance with radiologist readings (SOR: C, very small subsequent diagnostic accuracy studies).

Objective: The chasm theory of marketing states that fundamental differences exist between early adopters of technology and the mainstream marketplace, making it difficult for technology to transition to the mainstream market. We investigated possible differences in attitudes and beliefs about electronic medical records (EMRs) between current EMR users (early market) and nonusers (mainstream market)., Study Design: Cross-sectional mail survey., Population: Active members in the Indiana Academy of Family Physicians 2000-2001 membership database (N = 1328)., Outcomes Measured: Differences in attitudes, beliefs, and demographic characteristics of EMR users and nonusers., Results: The overall return rate was 51.7%; 14.4% of respondents currently use an EMR. Electronic medical record users were more likely to practice in urban areas or to be hospital-based and reported seeing fewer patients. Nonusers were less likely to believe that (1) physicians should computerize their medical records; (2) current EMRs are a useful tool for physicians; (3) EMRs improve quality of medical records and decrease errors; and (4) it is easy to enter data into current EMRs. Nonusers were more likely to believe that paper records are more secure and more confidential than EMRs. Both users and nonusers believed that current EMRs are too expensive., Conclusions: A chasm exists between EMR users and nonusers regarding issues that affect EMR implementation, including necessity, usefulness, data entry, cost, security and confidentiality. To reach full implementation of EMRs in family medicine, organizations should use these data to target their research, education, and marketing efforts.

Previous studies of after-hours calls to family physicians focused on caller demographics, medical triage skills, and patient satisfaction, and were usually conducted for a limited time. We examined the frequency and nature of calls to a family practice residency over 1 year. Caller and patient information, date, time, and chief complaint were obtained from answering service logs. The 5 most frequent chief complaints related to medications, pain, obstetric issues, fever, and nausea. Interestingly, 56 "high utilizers" (0.6% of all patients) accounted for 23% of the calls.

Objectives: Many managed care plans rely on primary care physicians to act as gatekeepers, which may increase tension between these physicians and specialists. We surveyed specialist physicians in California to determine whether their attitudes toward primary care gatekeepers differed depending on how the specialists were paid and the settings in which they practiced., Study Design: We performed a cross-sectional survey using a mailed questionnaire. The predictors of specialist attitudes toward gatekeepers were measured using chi-square, the t test, and regression analyses., Population: A probability sample of 1492 physicians in urban counties in California in the specialties of cardiology, endocrinology, gastroenterology, general surgery, neurology, ophthalmology, and orthopedics was used., Outcomes: We used questions about specialists' attitudes toward primary care physicians in the gatekeeper role. A summary score of attitudes was developed., Results: A total of 979 physicians completed the survey (66%). Attitudes toward primary care physicians were mixed. Relative to nonsalaried physicians, those who were salaried had a somewhat more favorable attitude toward gatekeepers (P = .13), as did physicians with a greater percentage of practice income derived from capitation (P =.002)., Conclusions: Specialists' attitudes toward the coordinating role of primary care physicians are influenced by the practice setting in which the specialists work and by financial interests that may be threatened by referral restrictions. Policies that promote alternatives to fee for service and shift specialty practice toward more organized group settings may generate a common sense of purpose among primary care physicians and specialists.

Background: We hoped to determine the attitudes and practices of primary care physicians regarding the use of opioids to treat chronic nonmalignant pain (CNMP). We also examined the factors associated with the willingness to prescribe opioids for CNMP., Methods: A survey was mailed to primary care physicians in the University of California, San Francisco/Stanford Collaborative Research Network. This survey contained questions regarding treatment in response to 3 case vignettes, the use of opioids for CNMP in general, and the demographic characteristics of the physicians., Results: Among 230 physicians surveyed, 161 (70%) responded. Two percent of the respondents were never willing to prescribe schedule III opioids (eg, acetaminophen with codeine) as needed for patients with CNMP that persisted unchanged after exhaustive evaluation and attempts at treatment. Thirty-five percent were never willing to prescribe schedule II opioids (eg, sustained-release morphine) on an around-the-clock schedule for these patients. The most significant predictor of willingness to prescribe opioids for patients with CNMP was a lower level of concern about physical dependence, tolerance, and addiction., Conclusions: Primary care physicians are willing to prescribe schedule III opioids as needed, but many are unwilling to use schedule II opioids around the clock for CNMP. Individual prescribing practices vary widely among primary care physicians. Concerns about physical dependence, tolerance, and addiction are barriers to the prescription of opioids by primary care physicians for patients with CNMP.

Background: When faced with questions about patient care, family physicians usually turn to books in their personal libraries for the answers. The resources in these libraries have not been adequately characterized., Methods: We recorded the titles of all medical books in the personal libraries of 103 randomly selected family physicians in eastern Iowa. We also noted all clinical information that was posted on walls, bulletin boards, refrigerators, and so forth. Participants were asked to describe their use of other resources such as computers, MEDLINE, reprint files, and "peripheral brains" (personal notebooks of clinical information). For each physician, we recorded how often the resources were used to answer clinical questions during 2 half-day observation periods., Results: The 103 participants owned a total of 5794 medical books, with 2836 different titles. Each physician kept an average of 56 books in the office. Prescribing references (especially the Physicians' Desk Reference) were most common (owned by 100% of the participants), followed by books on general internal medicine (99%), adult infectious disease (89%), and general pediatrics (83%). Books used to answer clinical questions were more likely to be up to date (copyright date within 5 years) than unused books (74% vs 27%, P <.001). Items posted on walls included drug dosage charts and pediatric immunization schedules. Only 26% of the physicians had computers in their offices., Conclusions: Drug-prescribing textbooks were the most common type of book in family physicians' offices, followed by books on general internal medicine and adult infectious diseases. Although many books were relatively old, those used to answer clinical questions were generally current.

Background: Visiting patients at home has long been one of the activities of the family physician, but the practice of making house calls has diminished significantly during the second half of the 20th century. The goal of this study was to describe physicians' attitudes about house calls and their practice of making them in the rapidly changing health care environment of the United States., Methods: A 30-item, self-administered questionnaire was designed to obtain demographic information about physicians and their attitudes toward house calls, practice experiences with making house calls, and any additional factors that influence making house calls. It was mailed to all members of the Colorado Academy of Family Physicians, during the summer of 1997., Results: A 66% response rate was obtained from practicing physicians. Overall attitudes toward house calls were positive. Fifty-three percent of the respondents reported making house calls, and 8% reported making more than 2 house calls per month. Male physicians, those older than 40 years, those in rural settings, and those trained in a community-based residency were more likely to make house calls. Patient payer mix and practice setting were also related to whether a physician made house calls. House calls were most frequently made to geriatric patients, cancer patients, trauma patients, and patients with transportation difficulties. Many physicians reported using home health agencies for assessment and treatment of patients needing home care., Conclusions: Family physicians agree that house calls are good for patients. More than half of the respondents reported that they occasionally make house calls. However, few physicians routinely perform house calls.

Background: Many physicians today are employed by another physician, group, hospital, HMO, or other organization. However, the differences in the characteristics, practice patterns, and patient outcomes of self-employed and employed physicians are not well understood., Methods: The practices of 108 community family physicians in northeast Ohio were assessed using a multimethod cross-sectional design. Physician characteristics were assessed by questionnaire. Direct observation of 3536 consecutive patient visits was used to measure time use and the delivery of preventive services recommended by the US Preventive Services Task Force. Patient satisfaction was assessed with the Medical Outcomes Study (MOS) 9-item Visit Rating Form., Results: Employed physicians were more likely to be female, in group practice, work fewer hours, and see fewer patients. Job satisfaction was similar between the two groups, but employed physicians reported greater satisfaction with leisure and family time. Employed physicians spent more time per patient visit, scheduled a larger percentage of well-care visits, and were more likely to refer to specialists. Employed physicians also spent a greater proportion of their patients' visit time performing history-taking and eliciting family information, and a lesser proportion of time on physical examination, planning treatment, providing health education, and chatting. Recommended screening and health habits counseling preventive services were more likely to be delivered by employed physicians. Patient satisfaction was similar for the two groups., Conclusions: Primary care physician characteristics and practice patterns differ by employment status. The consequences of the trend toward a largely employed physician workforce as reported in this study should be carefully considered.

Background: Managed care practice arrangements, or health maintenance organizations (HMOs), are sufficiently mature to examine whether physicians' level of satisfaction has changed as managed care has developed. This study compares Dane County, Wisconsin, physicians' satisfaction with HMO and fee-for-service (FFS) practices in 1986 with that of 1993 and examines factors that contribute to satisfaction in an HMO-dominated environment., Methods: Cross-sectional surveys were mailed to all Dane County physicians in active practice in 1986 and 1993. Physician overall support for HMO development and satisfaction with work situation was measured with single items. Overall satisfaction and clinical freedom within HMO and FFS practices were measured using statistically reliable scales., Results: Significantly more physicians were supportive of the development of HMOs in 1993 than in 1986, and more than two thirds of physicians in 1993 were satisfied in their current work situation. Primary care physicians were significantly more satisfied than subspecialists across most dimensions of satisfaction. Perceived clinical freedom and satisfaction with income continued to be major predictors of satisfaction in 1993 as in 1986. While physicians' satisfaction with HMO practice remained stable, their satisfaction with FFS practice was significantly lower in 1993 than in 1986. Satisfaction with Medicare practice, which was not measured in 1986, was significantly less than with HMO or FFS practice in 1993., Conclusions: Analyses suggest that primary care physicians are more satisfied than subspecialists with their HMO practice because of their greater satisfaction with HMO-generated income and the expanded clinical freedom they have in HMO practice. An across-the-board decline in satisfaction with FFS practice may be attributable to diminishing clinical freedom resulting from indemnity carriers' increasing micromanagement of patient care.

Background: The use of clinical guidelines is one strategy intended to improve health care quality, rein in costs, and standardize medical practice. Clinical guideline development has been prodigious, while less effort has been expended on the guidelines' dissemination and implementation. This study examines family physician attitudes toward and perceived uses of clinical guidelines in practice., Methods: A survey questionnaire was sent to 978 family physicians in Upstate New York to assess their confidence in clinical guidelines developed or endorsed by organizations and the perceived usefulness of such guidelines in practice. Descriptive analyses, chi-square tests, and comparison of means (one-way ANOVA) were conducted., Results: After two mailings, the response rate was 43%. Most respondents perceived clinical guidelines as effective educational tools that should improve the quality of patient care, but were concerned about their potential regulatory intrusion into practice. Solo practitioners expressed more negative attitudes regarding clinical guidelines than physicians in non-solo practices. Respondents had greater confidence in clinical guidelines developed or endorsed by their professional society, the Centers for Disease Control and Prevention, the United States Preventive Services Task Force, and the National Institutes of Health, but less in those by insurance companies or state health departments. The reported adoption rate of clinical guidelines was low. The most preferred methods for adoption were continuing medical education and practice interventions., Conclusions: Family physicians found clinical guidelines to be valuable educational tools but were divided on their potential regulatory role. If clinical guidelines are to improve quality in practice, they must be more effectively disseminated and implemented. To broaden physicians' adoption of clinical guidelines, further research into dissemination and implementation methods is warranted, along with wider endorsement of guidelines by those whom family physicians trust.

Background: Physicians often have unanswered clinical questions. The purpose of this study was to determine how often the answers to these questions can be found in the medical literature., Methods: We collected unanswered clinical questions from family physicians at the end of clinical half-days. The authors and medical librarians then used textbooks and MEDLINE to find answers to each question. We returned to the physicians one to five selected references for each question. Each physician rated these sources on how well they answered the questions and how they might influence the physician's practice., Results: One hundred three questions were gathered. Physicians asked an average of 0.5 questions per half-day. We searched for answers to 86 questions, and the physicians returned ratings for 84. Forty-five (54%) of these questions were fully or nearly fully answered by the materials returned to the physicians. Of the questions for which answers were found, MEDLINE searches accounted for 71%; textbooks, 20%; and a combination, 9%. MEDLINE searches took an average of 27 minutes, whereas textbook searches averaged 6 minutes., Conclusions: The medical literature can provide answers to a majority of clinical questions; however, finding these answers is time-consuming and expensive. Physicians need more efficient ways to answer their clinical questions.

Background: The number of family physicians delivering babies in Florida in 1991 was at an all-time low. Concerns about malpractice risk and insurance costs have resulted in only 2% of Florida's family practice residency graduates choosing to deliver babies. The purpose of this study was to compare the practices of family physicians in Florida who delivered babies in private practice (termed the "OB group") with those who did not (the "non-OB group")., Methods: A potential study group of 293 family physicians was mailed an extensive survey that explored 132 variables related to medical practice economics and demographics, lifestyle and satisfactions, and malpractice costs and risks., Results: The obstetrical (OB) group was significantly more likely than the non-OB group to perform a variety of procedures and report more patients under age 6 years (15% vs 5%; P = .003) and fewer patients 65 years or older (19% vs 33%; P < .001). Even though the number of patients seen and the number of hours worked were similar, the 1991 incomes were much higher for those practicing maternity care (mean = $164,000 vs $104,000; P = .04). Compared with the non-OB group, the OB group was more likely to report that their financial and psychological compensation was adequate (P < .001), would be more likely to choose medicine as a profession again (94% vs 60%, P < .05), paid more for malpractice insurance (mean = $22,000 vs $11,000; P = .01), and reported 30% fewer nonobstetrical malpractice claims., Conclusions: Family physicians in Florida who deliver babies, as compared with those who do not, are more likely to report (1) increased financial and psychological satisfaction for the same hours worked; (2) increased satisfaction with medicine and family practice; (3) more frequent performance of a wider range of procedures; (4) younger practices serving a greater number of complete families and fewer Medicare patients; (5) a more diverse and comprehensive hospital and office practice; and, despite paying significantly higher malpractice insurance premiums, (6) few obstetrical malpractice claims and lawsuits, and (7) fewer nonobstetrical malpractice claims and lawsuits.

Background: Family physicians must make complex decisions regarding which procedures to learn in training and which to perform in practice. Factors that influence these decisions include community needs, the potential profitability of a procedure, and the desires and skills of the individual physician., Methods: To further clarify some of these influences, we surveyed members of the Wisconsin Academy of Family Physicians. The survey instrument included questions about 27 different procedures, including the perceived profitability of the procedure, which procedures they had discontinued, and which they planned to learn., Results: More than 40% of family physicians reported doing skin surgery, flexible sigmoidoscopy, nonstress obstetrical testing, breast-cyst aspiration, multiple joint arthrocentesis, and Norplant insertion, whereas fewer than 6% perform colonoscopy, esophagogastroduodenoscopy, and nasolaryngoscopy. Fifty-seven percent of physicians had discontinued at least one procedure, and 34% planned to learn one or more procedures. Being younger, male, and practicing in smaller communities correlated with performing a greater number of procedures (P < .001), but female physicians performed more gynecologic procedures (P < .05). There was a statistically significant correlation (r = -.478, P < .05) between perceived low profitability of a procedure and family physicians discontinuing a learned procedure, and a marginal correlation between perceived profitability and planning to learn a procedure (r = .338, P < .1)., Conclusions: Family physicians in Wisconsin vary greatly in the number and types of procedures performed. Community size, sex, and age are important variables associated with the number and type of procedures performed. The performance of procedures is dynamic: physicians both discontinue learned procedures and learn new procedures. The profitability of the procedure influences the learning and discontinuation of procedures.

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.

Background: Physicians' satisfaction with their professional life influences the quality of patient care they provide and helps to determine the number and type of students attracted to the various fields of medicine. In this study, we sought to delineate areas of satisfaction and dissatisfaction among family physicians., Methods: A self-administered questionnaire was sent to all physicians in the state of Pennsylvania who were included in the 1990 directory of the American Board of Family Practice (N = 1944)., Results: Completed questionnaires were received from 1066 family physicians in full-time practice. Sixty-five percent were satisfied with their professional lives. Patient relationships, a sense of clinical competence, and their relationships with their partners were among the most satisfying aspects of practice for all family physicians. Problems identified included regulations by third-party payers and government agencies and the large amount of paperwork encountered in practice. There were significant (P < .001) differences in satisfaction between physicians in different practice arrangements. Significant differences between practice types were also found in the degree of dissatisfaction with third-party payers and government agencies, paperwork, isolation from other physicians, and the threat of a malpractice suit., Conclusions: Almost two thirds of family physicians are satisfied with their general professional lives. Conversely, one third are not. Clear areas of satisfaction and dissatisfaction have been defined for family physicians in general as well as for family physicians in various practice environments. This information may be useful in the development of policy to structure a medical system that meets the needs of both patients and physicians.

Background: Family-oriented patient care is a cornerstone of family practice. Family practice educators have proposed various methods to help the physician to better assess and treat families. Little is known, however, of the usefulness of family-oriented clinical tools to practicing physicians., Methods: On a mailed survey questionnaire, 595 members of the Wisconsin Academy of Family Physicians were asked to rate the usefulness of 10 family-oriented tools and indicate the frequency of use and level of training received for each item. In addition, physicians rated their current and desired level of competency for involving families in patient care., Results: Two hundred ninety-nine (50%) physicians responded. Most of the tools were rated as useful but used infrequently. Identifying the effects of chemical dependency on the health of families and conducting family conferences were rated as highly useful and frequently used skills. Clinical tools rated as least useful were record keeping by family charts and folders and family function assessment by the Family APGAR: Physicians who had received training in the use of a tool rated it as more useful, except for the Family APGAR and family charts or folders. Physicians with busier practices rated some of the tools as less useful than did other physicians. Respondents indicated a desire to develop their family counseling skills., Conclusions: Most family-oriented tools were reported to be useful but used infrequently by practicing physicians. Residency programs should continue to provide training for assessing and treating families, particularly in the areas of family systems theory, self-awareness of the physician's own family background, and the effect of chemical dependency on families. Future research should target larger and more varied groups of family physicians.

Background: Although the cost of prescription drugs is recognized as an important facet of health care expenditures, many physicians are purportedly unaware of actual drug costs. To test this hypothesis, we surveyed physician awareness of the cost of 20 actively marketed prescription drugs., Methods: A questionnaire listing four possible cost categories for each drug was administered to 305 registrants of a 5-day family medicine continuing education course., Results: Ninety-two physicians completed the questionnaire. Only one, a 40-year-old, board-certified physician who had been in practice for 3 years, answered 70% of questions correctly. The average score for the other participants was 37% (range 0% to 75%)., Conclusions: The majority of physicians questioned could not accurately identify the price range of commonly prescribed drugs. We recommend drug cost disclosure in drug advertising to help address this problem.

Background: Physicians must be able to rapidly obtain information that answers specific patient-related clinical questions. This study describes the information-seeking process in the office practices of family physicians., Methods: We observed and recorded the information-seeking and information-obtaining behavior of 30 family physicians in their offices., Results: Based on 172 hours of observation and 602 patient visits, family physicians sought answers to an average of only one clinical question for every 15 patients seen. Urban physicians sought answers to more questions than rural physicians (one question for every 9 patients, as compared with one question for every 24 patients; P less than .05). The frequency of seeking information was not related to the physician's age. Busier physicians (those seeing more patients per hour) tended to ask fewer questions (correlation coefficient (r) = -.34, P = .06). Drug-prescribing questions were the most common type; second most common were orthopedic questions. Colleagues and the Physicians' Desk Reference were the most often used resources. Eight percent of the questions were not answered., Conclusions: Among family physicians, patient-related questions are infrequently asked and highly specific. Most questions are rapidly answered using colleagues and books, not journals or computers.

Background: The risk of occupational exposure to the human immunodeficiency virus (HIV) may be one of the important issues facing family physicians in the 1990s. The use of universal precautions has been shown to reduce the incidence of exposures to bloodborne pathogens. Studies indicate, however, that these guidelines are not being followed consistently by physicians or their staffs., Methods: A survey of 3568 randomly sampled members of the American Academy of Family Physicians was performed using a questionnaire that was designed by the authors. Three mailings were conducted., Results: The total response rate was 39%. Approximately 80% of the respondents reported that they used gloves appropriately and disposed of sharp instruments in a puncture-resistant container. Only 39% "always" or "almost always" used eye protection when indicated, and only 35% "almost never" or "never" recapped used needles. There was a significant number of physicians who reported that they or their office staff had had an occupational exposure to bloodborne pathogens within the last year., Conclusions: Family physicians and their staffs do not uniformly follow universal precaution guidelines and, as a result, many have been exposed to blood products. If the physician or the office staff would not recap used needles and would place used sharp instruments in a puncture-resistant container, the greatest risks of occupational exposure would be reduced.

Background: Rapidly changing Medicare reimbursement policies since 1983 have affected every primary care physician. This study has attempted to quantify the attitudes and behaviors of Ohio primary care physicians toward these changes., Methods: In Ohio, 1758 primary care physicians were surveyed by a mailed questionnaire about their attitudes toward recent changes in Medicare reimbursement policies and the resulting changes in their practices., Results: More than 80% of respondents termed most Medicare policies as "objectionable" or "very objectionable." Fifty percent were limiting the number of Medicare patients in their practices. Family physicians and physicians who perceived their income to have decreased and their staff workload to have increased were also more likely to limit the number of Medicare patients in their practices., Conclusions: Ohio primary care physicians have a negative opinion of Medicare reimbursement policies and have limited their practices significantly as a result.

Background: This study describes billing practices of family physicians. Significant increases in the reimbursement for family physicians are expected from implementation of the resource-based relative value scale (RBRVS). However, the real impact of the RBRVS is unknown since little is known about how family physicians use the present reimbursement system to charge their patients., Methods: A random sample of 270 North Carolina family physicians was surveyed, using standardized progress notes of five hypothetical patients., Results: One hundred thirty-eight (51%) physicians responded; 107 (77.5%) were in private practice. Family physicians in private and nonprivate practices were similar in their Current Procedural Terminology (CPT) coding and level of service for each hypothetical case. Family physicians in smaller communities showed greater variation in CPT coding of visits than did family physicians in larger communities, and they were more likely to use CPT codes that indicated a lower level of visit. Rural family physicians demonstrated a significant inverse relationship between the CPT level of visit coded (ranging from "brief," with a CPT code of 90040, to "comprehensive," coded CPT 90080) and the amount they charged established patients for a "limited" visit (CPT 90050)., Conclusions: These findings suggest that the lower income of rural physicians is due, in part, to billing at a lower CPT code, and thus charging less for comparable services, than urban physicians. The findings also lend further support to contentions that federal reimbursement reforms will have less impact on the incomes of rural physicians than originally expected.

In response to the obstetric malpractice crisis, both obstetrician-gynecologists and family physicians have raised their fees and preferentially selected lower risk patients. In addition, large numbers of general and family physicians have left obstetric practice altogether. The impact of these responses was explored by examining the differences in the demographic and clinical profile of patients served by these two disciplines in the State of Washington. Eighty-five percent (45,540) of all complete records from 1983 births attended by physicians in the State of Washington were matched to physician specialty information. These births represent 67% of the total deliveries in Washington State in 1983. Although twice as many general and family physicians as obstetricians were practicing obstetrics, obstetricians delivered 2.5 times as many infants as did general and family physicians. Obstetricians served an older patient population with more low-birthweight infants, multiple births, and complications of pregnancy than family physicians. General and family physicians were more likely to care for minorities, teenagers, and unmarried and rural mothers. Obstetricians cared for patients with higher medical risks, whereas general and family physicians provided care to more socially vulnerable and geographically isolated populations. To the extent that general and family physicians are differentially abandoning obstetric practice because of the current malpractice crisis, access to care for rural and socially vulnerable groups may deteriorate rapidly.

A study was undertaken to determine (1) the likelihood that patients seen for episodic health care in a family medical center have been assessed and counseled for coronary heart disease (CHD) risk factors, and (2) the likelihood that patients having an identified risk factor have been assessed and counseled regarding other CHD risk factors. One thousand five hundred twenty-eight medical records were randomly selected from all visits occurring over two periods in 1986 and 1987 to 122 residents in an eight-site family medicine residency network. Patients with cardiovascular disease and those younger than 20 or older than 65 years of age were excluded. Assessments were made of (1) smoking history, blood pressure, weight, physical activity, and dietary content during the previous 12 months; (2) family history of cardiovascular disease during the previous 12 months and in the initial patient history; (3) and blood cholesterol during the prior 5 years. Risk-factor counseling practices were examined for the previous 12 months. Blood pressure was assessed in 96% of patients, smoking in 40%, cholesterol in 26%, and family history in 52%. Ninety-six percent of hypertensive patients were counseled for hypertension, but only 45% of smokers and 20% of patients with hypercholesterolemia were counseled for those risk factors. Of patients having a given risk factor, assessment for any other risk factor occurred in fewer than 60% of cases. Patients having a documented positive family history were only slightly more likely than other patients to be assessed for additional risk factors. There is continued need for enhancing coronary risk-factor assessment and counseling by resident physicians.(ABSTRACT TRUNCATED AT 250 WORDS)

A study was designed to investigate the status of obstetric practice by Pennsylvania family physicians and its relationship to family practice residency training. A 50% probability sample of all family and general physicians and of all graduates of Pennsylvania family practice residency programs was surveyed by mail. Ten percent of Pennsylvania family physicians and general practitioners reported currently practicing obstetrics, 44% of whom said they planned to stop within 3 years. Telephone survey information from nonresponders suggests that even fewer (5%) of the state's family physicians may actually be practicing obstetrics. Family practice residency training, postresidency obstetric training, and small community size were the best predictors of current obstetric practice. Family physicians in the smallest communities, however, were also those most likely to be planning to stop, and graduates of residency programs were increasingly choosing not to practice obstetrics. Cost of liability insurance and fear of lawsuits were primary reasons cited for stopping obstetrics. Family physicians have been major providers of obstetric care in the nation's rural areas. Now, increasingly firm evidence that fewer family physicians are practicing obstetrics signals increasing shortages in obstetric care for women in rural communities. Changes in the practice climate and obstetric training programs for family physicians seem essential to help reverse these trends.

Because of the pivotal role of medical knowledge in clinical problem solving, it is important to understand how clinicians decide to seek additional knowledge for patient care decisions and how they choose among the resources available to them. Using a self-administered questionnaire, 126 family physicians reported their use of 11 types of knowledge resources for answering patient-specific questions arising in clinical practice. They reported almost daily use of the Physicians' Desk Reference and more often than weekly use of colleagues. There was little use reported of Index Medicus or computer-based bibliographic retrieval systems. The research literature of medicine was used infrequently and rated among the lowest of resources in terms of credibility, availability, searchability, understandability, and applicability. In deciding among a subset of knowledge resources for answering a clinical practice question, resource cost variables related to clinical availability and applicability of the information to the problem at hand appeared to be more influential in the minds of physicians than factors related to quality of the resource. These findings have important implications for the development and deployment of knowledge resources intended to be useful and used in clinical practice.

To determine the relative importance of factors influencing the withdrawal of family physicians from maternity care, two studies, one done in Ontario, Canada, and the other done in the United States, were compared. The proportion of residency-trained family physicians who provide maternity care at the initiation of their careers and the proportion who have given up maternity care are nearly identical in the United States and Canada. Both studies found that about one half of the family physicians who currently provide maternity care were giving consideration to stopping. The reasons underlying this withdrawal were multifactorial. Malpractice issues were the predominant concern of United States family physicians, but the data from the studies indicate that other issues, such as interference with lifestyle and office practice and the effect of attitudes of obstetricians, should not be overlooked.

A case study was undertaken to analyze the effect of the loss of a primary care physician upon the population he served. While the physician in this study retired, the effects of his retirement can be extrapolated to the situations of sickness, death, etc, in which the services of a primary care physician are lost. A sample population of the patients who had lost their "family doctor" was interviewed in depth regarding the problems incurred by this loss. The mechanisms of informing the patients, transfer of patient records, exchange of responsibility and continuity of care, patterns of primary vs specialty care, and use of the Emergency Room before and after the retirement were investigated. It was found that only one out of every six families established a reliable and permanent relationship with a new physician within six months without experiencing "great difficulty". While recognizing the limitations of one case study, recommendations are made to mitigate the "difficult" aspects of such transfers in the future.

This study examines to what extent family practice patients perceive themselves as being willing to seek help for personal problems. The study further explores whether this willingness is related to various demographic characteristics. Finally, it investigates family practice patients' preferences in their choice of a source of help for personal problems. Patients in the waiting room of a private family practice center were approached to participate in the study at random times during one month (n = 145). For each item of a list of common personal problems, patients were asked to judge how likely they would be to seek professional help, their preferred setting for this help, and their preference of a professional provider. Respondents' sex was found to be the only demographic characteristic that affected willingness to seek help. "The family physician's office" and "the family physician" were the preferred choices mainly for personal problems associated with physical manifestations. Other providers were chosen for predominantly social or emotional problems. Most respondents stated that they would be more likely to seek help from a mental health professional who worked along with the family physician than they would be to seek help from a professional housed elsewhere.

A fundamental claim of family medicine is that the family physician treats the "whole" family--an ideological principle that guides undergraduate and residency education. Using archival data obtained from a random sample of 500 patients in one group of family physicians, this study analyzed the extent to which this principle is carried out in practice. Physicians trained in family practice residency programs were compared with their colleagues. Family types and marital stability were also examined. Results indicate that in only 28 percent of families (excluding single person households) were all family members seen by the same family physician. This occurred despite the high preponderance and stability of traditional nuclear families in the practice. There was no significant difference in this rate between graduates and nongraduates of approved family practice residency programs.

Ten years' documented experience in a British Casualty Department shows that the family physician has a potentially large role to play in the accident and emergency services of his community. It is clear that a well-trained family physician in a properly equipped hospital department can care for the great majority of his patients' injuries, minor surgical operations, and anesthetic needs. This is especially so where group practice and helpful specialist colleagues provide a supportive framework for problem sharing. A case is made for education of all family practice students and residents in this large and important area of medicine.

House call attitudes and practice patterns of New Jersey family physicians were studied in order to assist residency programs in curriculum development. House calls were offered by 82 percent of the 290 physicians in the sample; no difference was noted between rural and urban or between younger and older physicians. The average number of house calls per week was 6.05, of which 4.71 and 1.34 were scheduled and emergency respectively. Patients who were elderly, home-bound, had suffered a stroke, had cancer or congestive heart failure made up the majority of those receiving house calls. This survey also showed that many of the physicians who stated that they do not "offer" house calls to their patients, did in fact perform them. These study results support the thesis that family practice residencies should develop criteria and a protocol for house calls. Among the results which may be expected following such an innovation are increased satisfaction for patients and physicians alike.

From a consecutive series of 3,847 headache patients, 1,331 patients who made first visits for new headache to 120 primary care physicians were studied for usual care over a 14-month period. Either tension or vascular headache was the initial diagnosis in 23.8 percent and 12.8 percent of patients, respectively. Nearly one half (47.8 percent) were classified as having headaches other than tension or vascular. A total of 15.3 percent of headaches were undiagnosed or were regarded as a mixture of traditional diagnostic designations. At first visit, most patients (76.6 percent) were managed without diagnostic tests. Drugs were prescribed for 73.6 percent, and advice was given for 58.6 percent. Only 2.0 percent of patients had computerized tomographic scanning ordered at first visit, although at least 46 percent met National Institutes of Health criteria, a finding with potential economic consequences of at least $2 billion. These findings suggest the need for reevaluation of diagnostic categories for headache, reevaluation of strategies for headache management, and further investigations of headache in primary care patients.

There is a need for a measure of the overall seriousness of a given family practice workload. In the past, such measurements have been attempted in various ways. In this work, the rubrics of the Canuck Book Classification (a classification of health problems in family practice) were rated for seriousness. There was sufficient agreement on 96 rubrics for them to be used as indicators of the seriousness of workloads in general. Some examples of the uses of the system are shown. Several difficulties were encountered; these are not insuperable, and the method deserves to be developed further.

This study examines the effects on patient satisfaction of the introduction of family medicine residents into the staff of an ongoing private practice that joined a Department of Family Medicine. Questionnaires were administered to clinic patients during a four-week period four months prior to when residents began seeing patients at the clinic and again five months after residents joined the clinic staff. Satisfaction at both times was high; however, significant declines from Time 1 to Time 2 were noted on most items. Analysis showed that this decline was not related to dissatisfaction within the residents. A questionnaire was also mailed to a sample of patients who had not visited the clinic more than once during the first year of the resident program there. Three fourths of these individuals still viewed themselves as patients of the clinic. Implications of these findings for family medicine residency training programs are discussed.