Family practice social work: a new area of specialization

Many physical problems presented to family physicians by their patients often involve psychosocial variables with stress being a major one. Though family medicine advocates a biopsychosocial focus, one that is compatible with social work, the psychosocial aspects of health are often ignored. The involvement of social workers in the private practices of family physicians to deal with such problems is discussed in this paper as a new area of specialization. Issues such as the medicine-social work gap and the financing of social work services in private family medical practice are also addressed. It is concluded that this should be considered a new area of specialization. However, social workers must take the initiative in its development.     

A study of the preferences of family practitioners and other primary care physicians in treating patients' psychosocial problems

Family medicine specialists claim that they treat patients' psychosocial problems as well as their biological problems. Forty-four family physicians and 130 other primary care physicians at two urban medical centers in a large city completed a questionnaire designed to identify if any differences existed in their preferred mode of treating patients' psychosocial problems. Seventy percent of the time, family physicians, like other primary care physicians, preferred referring patients with psychosocial problems to social workers and other mental health experts to treating psychosocial problems themselves. The study has implications for family medicine, social work, and health care planning in the United States.     

Do patient attitudes influence physician recognition of psychosocial problems in primary care?

Research has yielded consistent evidence of high levels of psychiatric morbidity and psychosocial problems among primary care patients, and recent studies have focused on improving physician recognition. These studies are based on the unexamined assumption that patients want their physicians to treat psychosocial disorders; thus, underrecognition is examined by analyzing characteristics of physicians and medical settings. Patient characteristics, particularly attitudes about the appropriateness of seeking help for psychosocial problems in primary care, have not been examined in relationship to underrecognition. This study directly focuses on patient attitudes about appropriateness of requesting care for psychosocial difficulties, the extent to which patients discuss difficulties with their physicians, and the degree to which physician recognition is explained by these patient characteristics. The study sample of 883 adult patients was drawn from 23 primary care practices. Over 70 percent of patients find it appropriate to turn to their primary care physicians for help with emotional distress, family problems, life stress, behavioral problems, and sexual dysfunction; however, only one fifth to one third of patients who have experienced difficulties have discussed these problems with their primary care providers. Attitudes about appropriateness are significantly related to physician recognition of psychiatric symptoms and family difficulties but account for limited variance in levels of recognition.     

Discussing spirituality with patients: a rational and ethical approach

BACKGROUND: This study was undertaken to determine when patients feel that physician inquiry about spirituality or religious beliefs is appropriate, reasons why they want their physicians to know about their spiritual beliefs, and what they want physicians to do with this information. METHODS: Trained research assistants administered a questionnaire to a convenience sample of consenting patients and accompanying adults in the waiting rooms of 4 family practice residency training sites and 1 private group practice in northeastern Ohio. Demographic information, the SF-12 Health Survey, and participant ratings of appropriate situations, reasons, and expectations for physician discussions of spirituality or religious beliefs were obtained. RESULTS: Of 1,413 adults who were asked to respond, 921 completed questionnaires, and 492 refused (response rate = 65%). Eighty-three percent of respondents wanted physicians to ask about spiritual beliefs in at least some circumstances. The most acceptable scenarios for spiritual discussion were life-threatening illnesses (77%), serious medical conditions (74%) and loss of loved ones (70%). Among those who wanted to discuss spirituality, the most important reason for discussion was desire for physician-patient understanding (87%). Patients believed that information concerning their spiritual beliefs would affect physicians' ability to encourage realistic hope (67%), give medical advice (66%), and change medical treatment (62%). CONCLUSIONS: This study helps clarify the nature of patient preferences for spiritual discussion with physicians.     

Family Practice Social Work

Many physical problems presented to family physicians by their paticnts often involve psychosocial variables with stress being a major one. Though family rncdicine advocates a biopsychosocial focus, one that is compatible with social work, the psychosocial aspects of health are often ignored. Thc involvement of social workers in the private practices of family physicians to deal with such problems is discussed in this paper as a new area of specialization. Issues such as the medicine-social work gap and the financing of social work services in private family medical practice are also addressed. It is concluded that this should be considered a new area of specialization. However, social workers must take thc initiative in its development.     

Educating family physicians to care for the chronically mentally ill

More than 50 percent of the chronically mentally ill receive their medical, psychiatric, and social support services from primary care physicians in the general health sector. Despite this high level of involvement with these patients, the majority of family physicians consider their training in the management of patients with mental disorders to be inadequate. This paper describes six categories of critical competencies that should be included in the mental health curricula of family physician training programs: therapeutic attitudes and skills, diagnosis and differential diagnosis, functional assessment, psychopharmacology, management of emergencies, and psychosocial treatments. It outlines the manner in which specific competencies could be incorporated in medical school, in family practice residency training, and in postgraduate continuing medical education as well as the specific elements included in each. The discussion is based on the assumption that more effective participation by family physicians in the treatment of chronic psychiatric illness requires active attention throughout the continuum of medical education.     

Family awareness demonstrated by family practice residents: physician behavior and patient opinions

Audiotapes of the visits of 50 new patients with 20 family practice residents were analyzed to determine how aware the residents were of their patients' families. The same patients' opinions about family awareness were elicited by interviews. Residents exhibited only limited family awareness. Despite this, patients thought that the residents showed more interest in family matters than they usually expected from a family physician. Patients thought the physicians were most interested in their family situations when they asked more questions about family matters. Physicians were seen as least interested when they asked few family questions and when they were absent from the examination room for a relatively high proportion of the visit. Physicians were much less likely to discuss family matters with a patient during a short visit for an acute problem than during a longer visit for a chronic problem or for health maintenance. Most patients identified physician attitudes and behaviors as more important obstacles to the discussion of family matters than patient attitudes. Patients generally wanted substantially more help from their family physician for family problems than they expected to receive.     

Sexual problems of male patients in family practice.

OBJECTIVES: Little is known about men's expectations of their family physicians regarding sexual disorders. Our goal was to evaluate the frequency of sexual problems among male patients in family practice and to assess their need for help. STUDY DESIGN: We performed a cross-sectional survey based on structured questionnaires answered by patients and physicians in German family practices. POPULATION: We approached 43 family physicians; 20 (43%) participated. On a single day all men 18 years and older visiting the participating practices were approached, and 307 (84%) took part in the survey. OUTCOMES MEASURED: Patients were asked about their frequency and type of sexual problems, their need for help, and their expectations of their physicians. The physicians described their perceptions and management of sexual problems in family practice. RESULTS: Nearly all patients (93%) reported at least 1 sexual problem from which they suffered seldom or more often. The most common problems were low sexual desire (73%) and premature ejaculation (66%). Occupational stress was considered causative by more than half of the men (107/201). Forty-eight percent considered it important to talk with their physicians about sexual concerns. However, most physicians initiated a discussion about sexual concerns only seldom or occasionally. There was a nonsignificant correlation between the physicians' assumed knowledge and the patients' wish to contact them in case of sexual problems (rho=0.26). CONCLUSIONS: The high frequency of self-reported sexual disorders and the hesitancy of family physicians to deal with this topic signals a neglected area in primary health care. Certain conditions, such as occupational stress, which may be associated with sexual concerns, should encourage the physician to initiate discussions about sexuality.     

Identifying potential family practice social work opportunities

The results of a survey of private primary care family physicians relative to their interest in having social workers associated with their practices are reported. There are several family physician and practice setting variables associated with a positive response to the question of whether family physicians have or would like to have a social worker associated with their practice. These findings should be beneficial to social workers interested in becoming established in family practice. Implications of these factors are discussed.     

Identifying Potential Family Practice Social Work Opportunities

The results of a survey of private primary care family physicians relative to their interest in having social workers associated with their practices are reported. There are several family physician and practice setting variables associated with a positive response to the question of whether family physicians have or would like to have a social worker associated with their practice. These findings should be beneficial to social workers interested in becoming established in family practice. Implications of these factors are discussed.     

Patients' attitudes toward physician involvement in family conferences

Patients' interest in family conferences was investigated using Doherty and Baird's concept of level of physician involvement with families. Patients entering two primary care clinics (N = 239) completed a questionnaire assessing their interest in physician level of involvement for each of six representative clinical situations: hospitalization for serious illness, new diagnosis of serious illness, depression, marital or relationship problems, stress-related symptoms, and frequent visits without improvement. Most patients indicated that they would want family conferences with their primary physician if a family member experienced hospitalization, new diagnosis of a serious illness, or depression. Slightly less than one half of the patients indicated that they would want family conferences for the remaining situations. Among those patients desiring family conferences, majorities responded that they would want their primary physician to provide all of Doherty and Baird's levels 2 through 5 (ongoing medical information and advice, feelings and support, systematic assessment and planned intervention, and family therapy), especially for hospitalization for serious illness and for depression. Most patients who indicated that they would want their physician to provide family therapy in the family conference also responded that they would want referral to a mental health professional for family therapy. The implications of these findings for clinical practice, residency training, and future research are discussed.     

Nutrition counseling in private practice: attitudes and activities of family physicians

A community approach to cardiovascular disease control is advocated for the United States because of the high disease incidence and prevalence relative to other countries. The goal of this approach is to change nutrition behavior of all members of the community. As part of a program to identify barriers to physician participation, a survey of a random sample of family practice clinical faculty in a midwestern state was made to determine (a) if physicians agree that it is appropriate to give nutritional advice to a patient who came to the clinic for another reason, (b) the proportion of patients given nutritional advice, and (c) the barriers to giving nutritional advice. Most physicians report that giving nutritional advice to patients visiting them for other reasons is considered appropriate, but almost half the physicians give advice about dietary fat, dietary sodium, or dietary fiber to fewer than 20% of their patients. Only about 10% of physicians give advice to more than 80% of their patients. Absence of elevated risk factor levels or nutritional disease is the most common reason for not giving advice. Perceived lack of patient interest and expectation of patient nonadherence are also barriers. Unpalatability of the diet is occasionally a barrier. Cost of the diet is not a consideration. From these data it is concluded that family physicians consider it appropriate to give nutritional advice to patients who are not necessarily seeking it, but the perception that patients do not need or want, and would not follow, the advice inhibits physicians from delivering nutrition messages in private practice.     

Sexually transmitted infections and private physicians in Peru, 2003.

OBJECTIVES: To analyze demographic and practice characteristics of private physicians in 10 cities of Peru, and to shed light on the role of private practice in the delivery of medical care to patients with sexually transmitted infections (STIs). METHODS: As part of an interventional trial designed to improve physician management of STIs in 10 cities in Peru, detailed information was compiled regarding numbers of physicians in each city. A door-to-door survey was then conducted within each city of all private and public medical offices and institutions. Each physician encountered who had a private practice was asked to answer a questionnaire regarding demographic information, medical education, specialty, type of private and public practices currently engaged in, number of STI cases seen per month, and average earnings per consultation. RESULTS: Of 2,060 physicians working in the 10 cities, 507 reported having a private practice, either exclusively or concurrently with other clinical positions. Almost all the private physicians (97.4%) reported managing cases of STIs. Regional differences among private physicians were found in physician density, gender, and place of medical training. In addition, significant variations by gender were seen in rates of specialization, earnings per consultation, and numbers of female patients with STIs seen per month. CONCLUSIONS: Studies of the physician workforce can provide meaningful insights for potential use in addressing public health problems. This study provides valuable information that can help understand the important role of private physicians in managing STIs in Peru.     

Rural-urban differences in primary care physicians' practice patterns, characteristics, and incomes

CONTEXT: Low salaries and difficult work conditions are perceived as a major barrier to the recruitment of primary care physicians to rural settings. PURPOSE: To examine rural-urban differences in physician work effort, physician characteristics, and practice characteristics, and to determine whether, after adjusting for any observed differences, rural primary care physicians' incomes were lower than those of urban primary care physicians. METHODS: Using survey data from actively practicing office-based general practitioners (1,157), family physicians (1,378), general internists (2,811), or pediatricians (1,752) who responded to the American Medical Association's annual survey of physicians between 1992 and 2002, we used linear regression modeling to determine the association between practicing in a rural (nonmetropolitan) or urban (standard metropolitan statistical area) setting and physicians' annual incomes after controlling for specialty, work effort, provider characteristics, and practice characteristics. FINDINGS: Rural primary care physicians' unadjusted annual incomes were similar to their urban counterparts, but they tended to work longer hours, complete more patient visits, and have a much greater proportion of Medicaid patients. After adjusting for work effort, physician characteristics, and practice characteristics, primary care physicians who practiced in rural settings made $9,585 (5%) less than their urban counterparts (95% confidence intervals: -$14,569, -$4,602, P < .001). In particular, rural practicing general internists and pediatricians experienced lower incomes than did their urban counterparts. CONCLUSIONS: Addressing rural physicians' lower incomes, longer work hours, and greater dependence on Medicaid reimbursement may improve the ability to ensure that an adequate supply of primary care physicians practice in rural settings.     

The nature and content of physician telephone calls in a private practice

Telephone encounters received by two physicians in a private rural family practice setting were examined over a 61-day sampling period. A total of 1,264 calls were received during the study period, with 905 (71.6 percent) being received in the office setting. An average of 10.4 calls per physician were received each day, and a mean of 16.2 minutes per physician was spent each day with telephone encounters. Each call was brief, lasting 1.6 minutes (standard deviation 1.5 minutes); administrative and personal calls each lasted significantly longer than other call categories (F = 20.8, P = .0001). More chronic disease diagnoses tended to be handled during office when compared with nonoffice telephone encounters. The majority of calls (932, or 83.1 percent) did not require a face-to-face visit as judged by the physician. Of the office calls, 58.2 percent were handled by the physicians through a message system rather than a direct physician telephone call. It is estimated that uncharged care over the telephone saved patients in this practice up to $150,000 per year.     

Continuity of care in a family practice residency program.

Continuity of care, one of the basic characteristics of family medicine, was studied over a 12-month period in a family practice residency program. Continuity was measured in three contact areas; office hours, after hours, and on the inpatient service. The intensity of continuity was defined at three levels, from encounters with the personal physician to those with physicians on other medical teams. Continuity was further assessed in relation to family encounters. Third year residents averaged 83 percent continuity with their individual patients and 70 percent with their assigned families. Residents from other years were noted to have lower levels of continuity. Similar figures were noted for family practice inpatients. Continuity of care in private practice occurs in about 80 percent of patient encounters and it seems reasonable and feasible to expect residency training programs to come close to this figure.     

Access to Spanish-speaking physicians in California: supply, insurance, or both

BACKGROUND: National studies report patients with limited English proficiency (LEP) have difficulty finding bilingual physicians; however, it is unclear whether this situation is primarily a result of an inadequate supply of bilingual physicians or a lack of the insurance coverage necessary to gain access to bilingual physicians. In California, 12% of urban residents are Spanish-speaking with some limited proficiency in English. The majority of these residents (67%) are uninsured or on Medicaid. METHODS: In 2001, we performed a mailed survey of a probability sample of primary care and specialist physicians practicing in California. We received 1364 completed questionnaires from 2240 eligible physicians (61%). Physicians were asked about their demographics, practice characteristics, whether they were fluent in Spanish, and whether they had Medicaid or uninsured patients in their practice. RESULTS: Twenty-six percent of primary care and 22% of specialist physicians in the 13 urban study counties reported that they were fluent in Spanish. This represented 146 primary care and 66 specialist physicians who spoke Spanish for every 100,000 Spanish-speaking LEP residents. In contrast to the general population, there were only 48 Spanish-speaking primary care and 29 specialist physician equivalents available for every 100,000 Spanish-speaking LEP patients on Medicaid and even fewer (34 primary care and 4 specialist) Spanish-speaking physician equivalents for every 100,000 Spanish-speaking physician equivalents for uninsured Spanish-speaking LEP patients. CONCLUSION: Although the supply of Spanish-speaking physicians in California is relatively high, the insurance status of LEP Spanish-speaking patients limits their access to the physicians. Addressing health insurance-related barriers to care for those on Medicaid and the uninsured is critical to improving health care for Spanish-speaking LEP patients.     

Family physician job satisfaction in different medical care organization models

OBJECTIVES: The aim of the present study was to estimate physician job satisfaction at the Mexican Institute of Social Security (IMSS), the Ministry of Health (SSA) and in the private sector, and to measure the association between these different family medical care organization models. METHODS: A comparative cross-sectional design was used to investigate the job satisfaction of family physicians in private and institutional family medicine clinics. Satisfaction was measured with a previously constructed and validated instrument. The instrument measures the satisfaction in four areas: 'global satisfaction', 'institution where the physician works', 'the patients' and 'themselves as physicians'. RESULTS: One hundred and seven IMSS physicians, 106 SSA physicians and 97 private physicians were selected randomly from a census according to the sample size. The sample was weighted. Fifty-one percent of IMSS and SSA physicians were dissatisfied, against 25% in the private sector, in the first three areas. Comparing the private model and the IMSS, differences were found (P < 0.0001) in the area of 'global satisfaction' [odds ratio (OR) = 2.47, 95% confidence interval (CI) 1.69-3.67], 'institution where the physician works' (OR = 2.12, CI 1. 45-3.13) and 'themselves as physicians' (OR = 1.84, CI 1.28-2.65). When the private/SSA groups were compared, the differences were similar (P < 0.0001). No differences were found in terms of 'the patients'. When stratifying, the risks increased in females, in the group aged 31-40 years and in specialists in family medicine. CONCLUSIONS: The organization model is associated with dissatisfaction in all areas, except in 'the patients'.     

Patients' attitudes to the relevance of nonmedical problems in family medicine care

A questionnaire was designed to document middle-aged patients' attitudes toward their family physicians' approach to their problems of daily living. Middle-aged patients were studied because they face numerous adaptational challenges and receive substantial medical care. Almost 90 percent of 116 patients interviewed indicated that they wanted to be asked about nonmedical problems as measured by life events, with this preference being more common among those under 55 years of age. Physicians expressed comfort in inquiring about life events; however, the patients reported that they were asked about such issues rarely or only occasionally. Although over two thirds of patients felt their physicians were sufficiently aware of their life events, those who recalled frequent questions by their physician were most likely to feel their physician was sufficiently aware. Implications of these findings on the physician-patient relationship are discussed.