Cardiac rehabilitation in a family practice setting

In January 1978, a cardiac rehabilitation program was begun at Fort Ord, California. The program is unique in being designed and run by family physicians. In the Medical Intensive Care Unit, the patient with a myocardial infarction is started on a graduated exercise program and a structured course concerning heart disease. Eight weeks after the infarction, the patient is asked to join an out-patient exercise class meeting three times a week. The patient's progress is followed by serial treadmill and blood tests. After training for six months, the patients have shown an increase in exercise tolerance and a decrease in incidence of readmission for cardiac disease. Most importantly, the patients have become actively involved in their own treatment.     

Management of hypercholesterolemia in a family practice setting

A study was undertaken to assess physician adherence and patient compliance with the National Cholesterol Education Program guidelines for the management of newly detected hypercholesterolemia. The study site was the Department of Family Medicine, Medical University of South Carolina, Charleston, a university-based family medicine residency program. All serum cholesterol levels measured between July 1, 1988, and September 30, 1988, were reviewed. Patients were classified as normal, borderline, or hypercholesterolemic based on serum cholesterol levels and coronary heart disease risk factors. Patients previously recognized to be hypercholesterolemic were excluded. Six months later, medical record reviews were performed for the 192 hypercholesterolemic and 107 borderline hypercholesterolemic patients. Only 39 of the hypercholesterolemic patients (20%) had received appropriate dietary therapy and follow-up. Patient compliance with physician recommendations was excellent. There was minimal unnecessary testing or treatment of borderline hypercholesterolemia. Low rates of appropriate management of hypercholesterolemia may be related to inadequate physician knowledge, low physician-perceived self-efficacy regarding dietary counseling, or time constraints.     

Mitral valve prolapse in a family practice setting

Mitral valve prolapse (MVP) syndrome is a relatively new clinical entity and fairly commonly encountered in clinical practice. The symptoms are often so vague that it is frequently not diagnosed or misdiagnosed for completely unrelated conditions. The recognition of MVP is important since the symptoms as well as the arrhythmias produced may be responsive to propranolol and the incidence of bacterial endocarditis is known to be increased. This paper reports on 25 patients with MVP in a family practice setting and compares this experience to recent literature on this problem.     

Abdominal pain in a university family practice setting

Abdominal pain is one of the most common complaints in the family practice setting. Abdominal pain has been the subject of many studies; however, the focus has been on abdominal pain as a final diagnosis rather than as a symptom or presenting complaint. A retrospective audit examined 133 charts of patients 18 years of age or older presenting to the University of Iowa Family Practice Center from July 1976 to October 1978. Abdominal pain, etiology undetermined, accounted for approximately one half of the final diagnoses. The patients tended to be young and female. Almost one half of the patients were seen only once for the problem. Conclusions concerning management are drawn, and suggestions for further studies are made.     

Correlates of screening mammography in a family practice setting

The medical records of 243 asymptomatic women aged 50 years or older were reviewed at a community-based family practice center to determine the proportion who had been referred for a screening mammogram and to identify correlates of mammography referral. Patient demographic characteristics, breast cancer risk factors, and characteristics of past patient-physician encounters were considered. Between July 1, 1981, and July 1, 1987, 40 (16 percent) of the women had received a mammography referral from their currently assigned physician. All but two of the women had actually obtained the mammogram. The primary predictors of mammography referral were the known risk factors for breast cancer: a family history of breast cancer (prevalence rate ratio [PRR] = 9.3, P = .001) and a history of benign breast disease (PRR = 7.9, P = .002). Other predictors included having a Papanicolaou test performed by the current physician (PRR = 4.1, P = .03), having a test for stool occult blood returned by the patient (PRR = 10.2, P = .003), having been instructed in smoking cessation by the current physician (PRR = 10.0, P = .05), and, possibly, being a former smoker (PRR = 4.6, P = .09). Patient demographic characteristics, other known breast cancer risk factors (age, obesity, alcohol use, and pregnancy history), and the sex of the physician were not predictive.     

LEEP in the family practice setting

BACKGROUND: We wanted to review our 7-year experience using the loop electrical excision procedure (LEEP) for the treatment of cervical dysplasia in a family practice residency setting in the rural South. METHODS: We conducted a retrospective study with data gathered from chart review of a mostly Medicaid and uninsured patient population of rural Southern women referred from outlying health departments or private practices within an 80-mile radius. The women received follow-up Papanicolaou smears, and outcome measurements were either recurrence of dysplasia or at least 1 year with two negative Papanicolaou smears. Any surgical tissue obtained after LEEP was used to ascertain residual or recurrent dysplasia. RESULTS: Rates of disease recurrence and incomplete excision of cervical intraepithelial neoplasia grade 2/3 (CIN 2/3) compared favorably with results published by expert US gynecologists but were worse than those reported by European authors, who excise all CIN (CIN 1, CIN 2, and CIN 3). CONCLUSION: CIN 2 and CIN 3 can be diagnosed and treated appropriately with LEEP in the setting of a family practice residency.     

Pediatric lead screening in a suburban family practice setting

BACKGROUND. The adverse effects of lead on behavioral and intellectual development have been recognized for many years. During the past 10 years several studies have shown that lead is toxic to children at levels previously thought to be harmless. Black children living in urban neighborhoods have been identified as being at greatest risk. METHODS. To determine whether children seen in a suburban family practice center were being exposed to lead, voluntary screening of 1-year-old patients was performed. RESULTS. Over a 7-month period venous specimens for blood lead level were obtained from 40 children. Seventeen (43%) of the children had levels of 0.0 to 0.2 mumol/L (0 to 4 micrograms/dL). Fifteen (38%) had levels of 0.24 to 0.43 mumol/L (5 to 9 micrograms/dL). Eight (20%) children had levels of 0.48 mumol/L (10 micrograms/dL) or greater. The highest value obtained was 0.82 mumol/L (17 micrograms/dL). Seventy-five percent of the children with significantly elevated lead levels resided in suburban communities. CONCLUSIONS. Children seen in a suburban family practice setting are at risk for lead exposure, and screening should be considered by primary care physicians who practice in nonurban settings.     

Comparison of two Papanicolaou smear techniques in a family practice setting

Papanicolaou smear adequacy is directly dependent upon endocervical cell recovery. Ineffective physician sampling techniques and advancing patient age are responsible for most inadequate smears. Two thousand four hundred seventy-eight routine Papanicolaou smears were reviewed from the Department of Family Practice and the Department of Gynecology for the presence of these cells. A retrospective review showed approximately 25 percent cell recovery in women aged over 45 years from both departments. Recovery on the family practice service, however, was 19.4 percent greater than recovery on the gynecology service for younger women (57 percent vs 37.6 percent). Two prospective interventions were introduced in family practice in an attempt to improve these rates. A combined spatula-saline swab technique did not improve cell recovery in either age group. A combined spatula-Cytobrush cell collector technique, however, dramatically improved endocervical cell recovery by 200 percent in older women and by 57 percent in younger women. This method significantly improves endocervical cell recovery and may therefore improve the value of the Papanicolaou smear as a cancer screening test.     

Telephone management of febrile young children in a family practice setting

To examine which factors are related to the telephone disposition of febrile children in a university family practice setting, telephone encounter records of a cohort of febrile young children were analyzed. No relationship was found between telephone disposition and a child's sex, age, or temperature, the latter two being well-known risk factors for occult and serious illness in febrile young children. There was a significant relationship between telephone disposition and telephone diagnosis. The lack of association between telephone disposition and either age or temperature of a child should be impetus for staff education concerning the telephone management of febrile children in this family practice.     

Recognizing factitious hypoglycemia in the family practice setting

BACKGROUND: Factitious hypoglycemia is a deliberate attempt to induce a low serum glucose level using either insulin or oral hypoglycemic agents. Sulfonylurea-induced hypoglycemia is more common than incidents of insulin abuse, and hypoglycemia caused by these oral agents is biochemically indistinguishable from insulinoma. METHODS: We describe a case of factitious hypoglycemia resulting from insulin abuse in an adult diabetic patient, review the essentials of glucose homeostasis, and describe diagnostic tests that allow a differential diagnosis. RESULTS AND CONCLUSION: Factitious hypoglycemia is associated with a higher incidence of suicide, depression, and personality disorders. Insulin-induced hypoglycemia can be detected by an insulin to C-peptide ratio that is greater than 1.0. In the absence of proof to the contrary, insulinoma should be considered the cause of hypoglycemia until another diagnosis is established. The generally poor prognosis for patients with factitious hypoglycemia underscores the importance of early recognition of factitious disorders.     

A randomized study of cancer screening in a family practice setting using a recall model

A randomized controlled study that evaluated a recall system and patient education material by mail in 178 asymptomatic female family practice patients aged 50 to 69 years showed no effect on the proportion of patients who had cancer screening tests (P = .20) and a significant adverse effect on the mean number of tests performed (P = .05) after 4 months. In a subgroup of previous compliers (those who had one or more tests 12 months before the study), however, there was a lower proportion of patients receiving one or more tests (P = .019) with a lower mean number of tests (P = .007) than previous compliers in the control group. Recall strategies for cancer screening tests need to be more extensively studied in the United States before they are routinely adopted in family practice.     

The prevalence,secrecy, and psychology of purging in a family practice setting

This study investigated the prevalence and correlates of purging behavior in females at a family practice outpatient clinic. Purging behaviors were self-induced vomiting, laxative use, and fasting. A history of purging was reported by 21% of 277 respondents. Fewer than one out of five purgers fit modified DSM-III criteria for bulimia. Fifty-eight percent of purgers had never told anyone about their purging, and only 2% had discussed it with a family physician. Also, feelings of “depression” were associated with secrecy. Apparently, many people practice purging, without necessarily developing bulimia. It is argued, on the other hand, that its secrecy has led to misunderstanding and a tendency to underreport its occurrence to physicians.     

Perceptions of family practice residents regarding health care and poor patients

The purpose of this study was to assess residents' beliefs about the poor. Residents from eight different Ohio residency programs completed the questionnaire (N = 130). No significant differences were found in beliefs about the poor based on resident age, year of residency training, size of the community in which the resident was raised, and percentage of low-socioeconomic-status patients cared for. Most residents perceived the welfare system as lacking; 83 percent agreed the poor are caught in a "cycle of poverty," 82 percent agreed welfare benefits cause the poor to be dependent upon the system, and 48 percent believed indigent women become pregnant and have babies so they can collect welfare support. Conversely, only one in four residents believed that most poor people become poor as a result of lack of effort on their part, and one in five believed that society is coddling the poor. The majority of residents believed that poor patients are more likely than others to miss appointments without canceling (73 percent), more likely to be late for appointments (51 percent), and less knowledgeable about their illnesses (80 percent). One in four residents believed that poor patients tend not to appreciate the work of physicians and nurses, and 43 percent claimed that the poor are more difficult patients. The majority of residents believed that the poor are unlikely to practice preventive health behaviors (72 percent) or to be compliant with their medical regimen (60 percent). Finally, 41 percent believed that poor patients usually care less than others about their own health status.