Physician-patient encounters: the structure of performance in family and general office practice

INTRODUCTION: The College of Physicians and Surgeons of Ontario, the regulatory authority for physicians in Ontario, Canada, conducts peer assessments of physicians' practices as part of a broad quality assurance program. Outcomes are summarized as a single score and there is no differentiation between performance in various aspects of care. In this study we test the hypothesis that physician performance is multidimensional and that dimensions can be defined in terms of physician-patient encounters. METHODS: Peer assessment data from 532 randomly selected family practitioners were analyzed using factor analysis to assess the dimensional structure of performance. Content validity was confirmed through consultation sessions with 130 physicians. Multiple-item measures were constructed for each dimension and reliability calculated. Analysis of variance determined the extent to which multiple-item measure scores would vary across peer assessment outcomes. RESULTS: Six performance dimensions were confirmed: acute care, chronic conditions, continuity of care and referrals, well care and health maintenance, psychosocial care, and patient records. DISCUSSION: Physician performance is multidimensional, including types of physician-patient encounters and variation across dimensions, as demonstrated by individual practice. A conceptual framework for multidimensional performance may inform the design of meaningful evaluation and educational recommendations to meet the individual performance of practicing physicians.     

A scale to measure physician beliefs about psychosocial aspects of patient care

This report describes the development and initial validation of a self-report instrument designed to measure beliefs about psychosocial aspects of patient care held by primary care physicians. The strategy used was borrowed from psychological measurement: a rational scale was constructed based on an existing theoretical framework concerning the physician's role, what the patient wants and physicians' reactions to their patients as people. The validation step compared scale scores obtained by diverse groups of providers. Psychometric characteristics of the Physician Belief Scale are adequate: scores follow an approximately normal distribution with the mean near the midpoint of possible scores. Lower scores on the Scale represent a more psychosocial approach to patient care. Initial construct validation was successful: physicians from four disciplines obtained scores congruent with expectations about the psychosocial orientations of the disciplines. A reliable and valid measure has been developed to assess physicians' psychosocial beliefs. The instrument may be used to evaluate effectiveness of behavioral science teaching, describing regional or other differences in physician beliefs within and between specialties and estimating changes in provider beliefs.     

Impact of Psychosocial Risk Factors on Prenatal Care Delivery: A National Provider Survey

To evaluate providers’ perspectives regarding the delivery of prenatal care to women with psychosocial risk factors. A random, national sample of 2,095 prenatal care providers (853 obstetricians and gynecologists (Ob/Gyns), 270 family medicine (FM) physicians and 972 midwives) completed a mailed survey. We measured respondents’ practice and referral patterns regarding six psychosocial risk factors: adolescence (age ≤19), unstable housing, lack of paternal involvement and social support, late prenatal care (>13 weeks gestation), domestic violence and drug or alcohol use. Chi square and logistic regression analyses assessed the association between prenatal care provider characteristics and prenatal care utilization patterns. Approximately 60 % of Ob/Gyns, 48.4 % of midwives and 32.2 % of FM physicians referred patients with psychosocial risk factors to clinicians outside of their practice. In all three specialties, providers were more likely to increase prenatal care visits with alternative clinicians (social workers, nurses, psychologists/psychiatrists) compared to themselves for all six psychosocial risk factors. Drug or alcohol use and intimate partner violence were the risk factors that most often prompted an increase in utilization. In multivariate analyses, Ob/Gyns who recently completed clinical training were significantly more likely to increase prenatal care utilization with either themselves (OR 2.15; 95 % CI 1.14–4.05) or an alternative clinician (2.27; 1.00–4.67) for women with high psychosocial risk pregnancies. Prenatal care providers frequently involve alternative clinicians such as social workers, nurses and psychologists or psychiatrists in the delivery of prenatal care to women with psychosocial risk factors.     

Country of origin, social support and the risk of small for gestational age birth

AIMS: This study investigates the risk of small for gestational age (SGA) in relation to country of origin of the mother. The role of psychosocial resources, socioeconomic and lifestyle factors was examined in different causal models. METHODS: Among all pregnant nulliparous women in the city of Malm?, Sweden, who gave birth in 1991--92, 872 (87.7%) women completed a questionnaire during their first antenatal visit. The study was carried out among women whose pregnancies resulted in a singleton live birth (n = 826); 22% (n = 182) of these women were foreign-born. RESULTS: Fifty-five (6.7%) of the infants were classified as SGA, 37 (5.7%) of mothers of Swedish origin and 18 (9.7%) of foreign origin. SGA deliveries were much more prevalent among Middle East- and North Africa-born women (22%) and sub-Saharan-born women (15%). In all, women of foreign origin had increased odds for delivering SGA babies (OR = 1.8, 95% CI = 1.0,3.2). In a multivariate analysis psychosocial and socioeconomic factors explained 30% and 40%, respectively, of the increased SGA risk. Psychosocial factors seemed to be more prominent risk factors for SGA among mothers of foreign origin. A possible synergistic relation was demonstrated between foreign origin of the mother and low social anchorage. CONCLUSIONS: This study showed that psychosocial factors, most probably linked to a disadvantaged social situation, could be the theoretically most important focus for preventing SGA in immigrant women. This could also further support a hypothesis of a link between psychosocial stress and SGA in general. However, this should not exclude the need for intervention in the antenatal care system in terms of specially tailored support and education.     

Antenatal care in Maputo, Mozambique.

Mozambique, within its plan for overall social and economic change, has given priority to primary health care with a principal focus on maternal and child health. In 1980 an antenatal control form was introduced into all Maputo's antenatal clinics to monitor pregnancies and to help direct specialist care to mothers at greatest risk--a strategy known by WHO as the "risk approach." In this study three health centres were selected from contrasting areas of the city. Almost 1000 completed antenatal forms were analysed to determine incidence of risk and to evaluate the implementation of this strategy. It was found that: (1) a considerable number of women at risk were identified, referred, and successfully monitored through their pregnancy. (2) Of those women at risk who were identified by the health centres, fewer than half were actually referred for specialist care. (3) Those women at greatest risk were not the highest users of the services, and many of them underused the services compared with those at lower risk. (4) The level of risk and child mortality varied with a measure of urban quality of the areas in which the centres were located.     

Relative importance of heritable characteristics and lifestyle in the development of maternal obesity

STUDY OBJECTIVE: To assess the relative importance of heritable characteristics and lifestyle in the development of "maternal obesity" after pregnancy. SETTING: South east London, in the homes of mothers who had delivered their babies at either Guy's, Lewisham or St Thomas's hospitals. PARTICIPANTS: Seventy four mothers of low antenatal risk who had been enrolled in the Antenatal Care (ANC) Project (a previous trial of antenatal care) during the first trimester of pregnancy, and who had subsequently been followed up 2.5 years after delivery. DESIGN: Information on parental obesity, psychosocial and sociodemographic factors as well as lifestyle, was gathered during a semi-structured interview at each mother's home. Additional anthropometric and psychosocial data were taken from the existing ANC Project database. These data were used to assess the relative importance of heritable characteristics and lifestyle on changes in maternal body weight from the beginning of pregnancy to the follow up interview. MAIN RESULTS: After adjusting for the effects of potential confounders and known risk factors for maternal obesity, women who selected larger silhouettes to represent their biological mothers were significantly more likely to have higher long term weight gains than those who selected thinner maternal silhouettes (r = 0.083, p = 0.004). Women who were less satisfied with their bodies postpartum had significantly greater long term weight gains than those women who displayed no increase in dissatisfaction with their bodies after pregnancy (r = 0.067, p = 0.010). CONCLUSIONS: A heritable predisposition to gain weight together with changing attitudes to body size, both had an independent role in the development of maternal body weight after pregnancy. Differences in each woman's heritable predisposition to gain weight and any changes in body image that occur after pregnancy might explain why some women gain weight in association with pregnancy.     

Knowledge and attitudes of primary care physicians regarding battered women. Comparison between specialists in family medicine and GPs

BACKGROUND: Domestic violence is a widespread public health problem and an important part of primary care practice. OBJECTIVE: To evaluate the approach of primary care physicians (family physicians and GPs) to the care of battered women. METHODS: A self-report questionnaire containing items about experience, knowledge and attitudes regarding the care of battered women was mailed to a random sample of 300 primary care physicians employed by the two major health management organizations in Israel. The population included family physicians, who have 4 years of residency training in primary care, and GPs, who do not undergo specialization after completing their medical studies. RESULTS: A total of 236 physicians (130 family physicians and 106 GPs) responded. In general, the physicians had had very little exposure to the problem and estimated its prevalence in the community as less than half that indicated in the medical literature. Compared with the GPs, however, the family physicians reported more exposure to the subject (P < 0.001) and had better knowledge of its prevalence and risk factors (P < 0.001). They also showed a greater tendency to view the problem as universal (P < 0.05) and as part of their professional responsibilities. However, both groups tended not to include the care of battered women with no physical injury within their professional duties. CONCLUSIONS: Physicians should be made more aware of the problem of battered women within the context of their routine professional practice and of the importance of keeping abreast of the subject. Educators should place more emphasis on imparting knowledge and skills in the management of battered women, especially for GPs.     

Physician peer assessments for compliance with methadone maintenance treatment guidelines

INTRODUCTION: Medical associations and licensing bodies face pressure to implement quality assurance programs, but evidence-based models are lacking. To improve the quality of methadone maintenance treatment (MMT), the College of Physicians and Surgeons of Ontario, Canada, conducts an innovative quality assurance program on the basis of peer assessments. Using data from this program, we assessed physician compliance with MMT guidelines and determined whether physician factors (e.g., training, years of practice), practice type, practice location, and/or caseload is associated with MMT guideline adherence. METHODS: Secondary analysis of methadone practice assessment data collected by the College of Physicians and Surgeons of Ontario, Canada. Assessment data from methadone prescribing physicians who completed their first year of methadone practice were analyzed. We calculated the mean percentage compliance per guideline per physician and global compliance across all guidelines per physician. Linear regression was used to assess factors associated with compliance. RESULTS: Data from 149 physician practices and 1,326 patient charts were analyzed. Compliance across all charts was greater than 90% for most areas of care. Compliance was less than 90% for take-home medication procedures; urine toxicology screening; screening for hepatitis B virus (HBV), hepatitis C virus (HCV), human immunodeficiency virus (HIV), tuberculosis, other sexually transmitted infections, and completion of a psychosocial assessment. Mean global compliance across all charts and guidelines per physician was 94.3% (standard deviation = 7.4%) with a range of 70% to 100%. Linear regression analysis revealed that only year of medical school graduation was a significant predictor of physician compliance. DISCUSSION: This is the first report of MMT peer assessments in Canada. Compliance is high. Few countries conduct similar assessment processes; none report physician-level results. We cannot quantify the contribution of peer assessment, training, or self-selection to the compliance rates, but compared to other areas of practice these rates suggest that peer assessment may exert a significant effect on compliance. A similar assessment process may in other areas of clinical practice improve physician compliance.     

Evaluation and management of occupational low back disorders

This clinical practice review of occupational low back disorders describes work-related risk factors, occupational history, physical evaluation, clinical tests, diagnosis, care, and prevention. It is part of a quality assurance (QA) and quality improvement (QI) effort to establish exemplary occupational practice standards. It emphasizes the involvement of occupational medicine physicians in exposure assessment, care of injured workers, and disease prevention. Important occupational risk factors such as lifting, awkward body posture and vibration, in addition to psychosocial, socio-economic and other factors are summarized. The focus is on mechanical back disorders. Return-to-work, rehabilitation and prevention strategies are discussed as part of integrated disability management involving the injured worker, the primary care provider, employers and other relevant parties.     

A geographic comparison of the prevalence and risk factors for postnatal depression in an Australian population

Objective: This study sought to compare the contribution of demographic and psychosocial variables on the prevalence of, and risk for, PND in urban and rural women. Methods: Demographic, psychosocial risk factor and mental health data was collected from urban (n=908) and rural (n=1,058) women attending perinatal health services in Victoria, Australia. Initial analyses determined similarities and significant differences between demographic and psychosocial variables. The association between these variables and PND case/non‐case was evaluated using logistic regression analysis. Results: There were a number of significant differences between the two cohorts in terms of socio‐economic status (SES), age, marital status and past history of psychopathology Antenatal depression was more common in the urban group compared to the rural group (8.5% vs 3.4%, p=0.006); there was no significant difference in the prevalence of PND (6.6% vs 8.5%, p=0.165). For urban mothers, antenatal EPDS score was the best predictor of PND. For rural mothers antenatal EPDS score, SES and psychiatric history had a significant influence on postnatal mood. Conclusions: Findings confirm the contribution of established risk factors such as past psychopathology, antenatal EPDS score and SES on the development of PND and reiterate the need for procedures to identify and assess psychosocial risk factors for depression in the perinatal period. Other predictors such as efficacy of social support and perceived financial burden may strengthen statistical models used to predict PND for women living in a rural setting.     

Gender differences in self-reported physical and psychosocial exposures in jobs with both female and male workers

OBJECTIVE: The aim was to determine whether men and women with the same job are equally exposed to work-related physical and psychosocial risk factors for musculoskeletal complaints. METHODS: Men (n = 491) and women (n = 342) in 8 jobs with both female and male workers completed a questionnaire on exposure to work-related risk factors. Gender, job title, and potential confounders were included in the final statistical models. Separate analyses were performed for desk workers and assembly workers. RESULTS: For most risk factors gender differences in exposure were found. Among desk workers exposures were most often higher for women, which was the opposite for assembly workers. CONCLUSIONS: Although exposure assessment relied on self-report, it seems unlikely that gender differences in reporting behavior completely explained gender differences in exposure. Thus, gender differences in exposure are present within the same job.     

Variability in physician management of employment during pregnancy.

BACKGROUND AND OBJECTIVES: Successful employment outcomes for pregnant women result from a complex interplay between the woman, her employer, her prenatal care provider, laws and other influences. METHODS: A mail survey about management of employment during pregnancy was sent to directors of US residency programs that train prenatal care providers. Each physician was randomly assigned one of 4 vignette patients whose job involved prolonged standing, rotating shifts and lifting 40 lbs. Half the vignette patients had risk factors for preterm birth and half would have financial difficulty if placed on an unpaid antenatal leave. RESULTS: The 301 respondents estimated that they provide a written job restriction for 20% of their employed pregnant patients, although in 6 clinics the job restriction rate was 100%. For vignettes with preterm birth risk factors, 62.5% of physicians would always recommend a job restriction, 35.6% would do so sometimes, and 2.2% would rarely do so. When the vignette did not have risk factors for preterm birth, 21.5% of the physicians would always recommend a job restriction, 51.3% would do so sometimes, 25.9% would do so rarely and 1.3% would never do so. Economic factors were not associated with prescribing job restrictions. One in 5 of the residency programs provides no teaching on occupational health issues in pregnancy, and 65.1% provide 2 hours or less. CONCLUSIONS: Variability in employment recommendations suggests that some women may not obtain the job modifications that they need, whereas others may be restricted unnecessarily. The limited curriculum time devoted to this topic may make it difficult to train physicians about complex employment issues during pregnancy.     

Technologies for pregnancy care

Identifying available technologies for antenatal care and points where new and improved ones are needed, the discussion reviews the following categories of risk and actions and their associated technologies: basic care for all women; risk assessment -- potential danger; immediate danger and immediate action. Aspects of program management, including goals, intervention strategies, record keeping, and training and supervision are also considered. All pregnant women need access to basic antenatal health care. The availability of such care allows high risk groups and individuals to be detected. An important aspect of basic antenatal health care is advice on how pregnant women can stay healthy. The importance of a good diet should be emphasized, and pregnant women should also be taught ways to prevent or relieve the minor discomforts of pregnancy. Women should be informed which conditions are normal during pregnancy and which are signs of danger. When pregnant women are receiving basic antenatal care, they should be assessed for factors that can indicate potential danger or complications at the time of delivery. Actions (including referral) can be taken at the primary care level to minimize the complications to which these factors may often lead. Long-range programs or social interventions beyond the usual boundaries of health care may be what is needed to reduce or eliminate these factors. Pregnant women, especially those in the last 3 months of pregnancy, should always be checked for signs of immediate danger so that early or emergency treatment can be provided. Warning signs and emergency treatment for eclampsia and preeclampsia, anemia, malaria, and other dangers are reviewed, including placenta previa, female circumcision, and sexually transmitted diseases. Other dager signs during pregnancy include decreases in fetal movements and fetal heart sounds. The major emphases of antenatal care are similar throughout the developing world, yet each country needs to develop its own strategy for implementation and to determine what the content of care will be. It may also be necessary to develop individual approaches for different regions within a country. Program goals can be determined by an assessment of local health problems and the selection of priorities. The selection of priority health problems is based on several criteria, including prevalence, seriousness, manageability, and level of community concern. For each health problem, each criterion needs to be assigned a weight. The weight is then added or multiplied to give a rank order. Selected priorities need to be examined in relation to overall national health policies and priorities. The best strategy for intervention depends on the available resources, including personnel, facilities, and equipment, and on the organization of services. A record keeping system is an essential component of an antenatal strategy. Antenatal services can be improved without technological developments. Well-designed support materials can greatly facilitate the introduction of new technologies and expand coverage of antenatal services.     

An economic evaluation comparing two schedules of antenatal visits

OBJECTIVES: To conduct an economic evaluation comparing a traditional antenatal visiting schedule (traditional care) with a reduced schedule of visits (new style care) for women at low risk of complications. METHODS: Economic evaluation using the results of a randomised controlled trial, the Antenatal Care Project. This took place between 1993 and 1994 in antenatal clinics in South East London and involved 2794 women at low risk of complications. RESULTS: The estimated baseline costs to the UK National Health Service (NHS) for the traditional schedule were 544 Pounds per woman, of which 251 Pounds occurred antenatally, with a range of 327-1203 Pounds per woman. The estimated baseline costs to the NHS for the reduced visit schedule was 563 Pounds per woman, of which 225 Pounds occurred antenatally, with a range of 274-1741 Pounds per woman. Savings from new style care that arose antenatally were offset by the greater numbers of babies in this group who required special or intensive care. Sensitivity analyses based on possible variations in unit costs and resource use and modelled postnatal stay showed considerable variation and substantial overlap in costs. CONCLUSIONS: Patterns of antenatal care involving fewer routine visits for women at low risk of complications are unlikely to result in savings to the Health Service. In addition, women who had the reduced schedule of care reported greater dissatisfaction with their care and poorer psychosocial outcomes which argues against reducing numbers of antenatal visits.     

Concurrent consultations with physicians and providers of alternative care: results from a population-based study

OBJECTIVE: We examined the factors related to consultations with both physicians and alternative practitioners, compared with visits to physicians only. METHODS: A telephone survey (random-digit dialling) collected information from 818 adults living in and around Saskatoon. Respondents reported consultations with alternative practitioners and physicians in the previous 12 months. RESULTS: Approximately one in five respondents had consulted both a physician and an alternative practitioner. Among respondents under 65 years of age, having one or more chronic medical conditions significantly increased the likelihood of concurrent use of care. Men, individuals suffering from back pain or migraines, those reporting an elevation level of distress, and those for whom spiritual values were important were also more likely to use both types of care. INTERPRETATION: Consultations with alternative care providers occur as an adjunct to, rather than a replacement of visits to physicians. Particular types of medical conditions as well as psychosocial and spiritual factors are determinants of concurrent use of physicians and alternative practitioners.     

Social class,ethnicity and attendance for antenatal care in the United Kingdom: a systematic review

BACKGROUND: Evidence from outside the United Kingdom points to several socio-demographic factors associated with late initiation of antenatal care or fewer antenatal visits, but it is not clear how generalizable these studies are to the UK context. This systematic review addresses the question of whether there are social or ethnic inequalities in attendance for antenatal care in the United Kingdom. METHODS: We identified and reviewed UK studies assessing attendance for antenatal care according to any measure of social class, social deprivation or ethnicity. A wide range of electronic databases was searched for published and unpublished studies. Further studies were identified from reference lists, citation searches and key organizations. RESULTS: From over 1300 identified papers, 20 were potentially relevant. Nine were included in the review. Most studies were of poor quality, with only one study controlling for the effect of potential confounders such as age, parity and clinical risk factors. All but one were based on data collected around 20 years ago. Three of the five studies looking at antenatal attendance and social class found that women from manual classes were more likely to book late for antenatal care and/or make fewer antenatal visits than other women. All four studies reporting on antenatal attendance and ethnicity found that women of Asian origin were more likely to book late for antenatal care than white British women. CONCLUSIONS: There is little good quality evidence on social and ethnic inequalities in attendance for antenatal care in the United Kingdom. Recommendations for further research are suggested.     

Risk factors for falls and injuries in a long-term care facility in Ontario

OBJECTIVE: To identify risk factors for falls and injuries among seniors living in a long-term care facility. METHOD: Case-control study of 335 residents living at St. Joseph's Villa, Dundas, Ontario. Cases were defined as residents who fell between July 1, 1996 and June 30, 1997; controls were those who did not fall. To identify risk factors for injury, cases were defined as those with completed incident injury forms and controls as those without. RESULTS: The most important risk factors for falls included: having fallen in the past three months; residing in a secured unit; living in the facility for two or more years; having the potential to cause injury to others; and having an illness, disease or behaviour that may cause a fall. The most important risk factor for injury among those who fell was altered mental state. CONCLUSION: The risk factors identified may be helpful to those planning falls prevention initiatives within long-term care settings.     

541例自然早产的高危因素分析

目的:探究自然早产的高危因素。方法:查阅自然早产病历541例为研究组,并对其进行1∶1配对,查取在分娩年份上有可比性的足月分娩病历541例为对照组,进行logistic回归分析,筛选早产的高危因素。结果:前次早产史、胎膜早破、妊娠期中度及重度贫血、多双胎妊娠、宫颈机能不全、孕妇外周血淋巴细胞记数升高是早产的高危因素;O型血、系统产检是早产的保护因素。结论:早产为多因素共同作用的结果,适当的产检可降低早产的发生率。     

The prevention of risk due to the manual lifting of patients: the psychosocial component]

A high percentage of musculoskeletal disorders in nursing staff with the task of patient lifting is reported in the literature. These disorders are considered to be of multiple etiology and attempts have been made not only to assess the physical load but also to identify the direct or indirect influence of organisational and psychosocial factors so that preventive measures be more appropriate and effective (Law 626/94). In this context, in a recent publication NIOSH recalled that psychosocial factors can alter the relationship between exposure to physical loads and the development or the prognosis of these disorders, and stresses that understanding these relationships is the crucial factor in assessment of exposure that can be addressed with preventive and therapeutic measures. A study was carried out on the staff (113 subjects) of a large hospital in northern Italy with departments recognised by certified occupational physicians as at risk for the musculoskeletal apparatus. In order to quantify the working conditions and the disorders of the spine, a protocol proposed by the Ergonomics of Posture and Movement Research Unit of Milan University was further developed and validated. For assessment of psychosocial factors an Italian version of R. A. Karasek's "Job Content Questionnaire" was drawn up and validated by the Centre for Study and Research of Chronic Degenerative Diseases in Working Environments of Milan University. In addition, Borg's Scale was used for perception of physical load, Kurimori and Kakizaki's Scale for mental fatigue, Kjellberg and Iwanowski's Scale for states of stress, plus the Maslach burnout inventory. Nonparametric statistical analysis was applied to determine the influence of physical and organisational and psychosocial factors on disorders of the musculoskeletal apparatus. The results confirm a good agreement between the objective and subjective assessments of "manual patient handling" risk (Kendall p from 0.26 to 0.37, p > 0.001) and the significant relationships between psychosocial factors and disorders of the lumbar region of the spine: past history of episodes of acute low back pain is associated with limited possibility of making independent decisions (U-Mann Whitney z = 2.81, p 0.004) and job insecurity (U-Mann Whitney z = -2.36, p 0.01); episodes of acute low back pain above the threshold in the previous year were associated with low discretionary powers at work. The results will be discussed on the basis of the possible prevention measures.     

Classification of obesity and assessment of obesity-related health risks

The barriers to the evaluation and treatment of obesity by health-care providers include a lack of awareness of obesity as an independent risk factor for morbidity and mortality and inadequate training in the medical management of obesity. However, the increased risk of medical disorders and emotional consequences associated with obesity make the disorder a priority for physicians to assess and treat. Obesity researchers have published and promoted the use of evidence-based, practical guidelines to educate physicians about how best to approach obesity as a medical disorder. The guidelines support classification and assessment of obesity as an important component of the patient's medical care. Assessment begins with classification by body mass index (BMI), with overweight and obesity defined as a BMI of 25 and 30 kg/m(2), respectively. Patients with high-risk combinations of BMI, waist circumference, and specific cardiovascular risk factors should begin a weight-loss program if no contraindications are present. Proper assessment also includes evaluation of complicating factors for obesity, such as sleep apnea and type 2 diabetes, psychosocial factors, and the use of medications that may contribute to obesity. Special attention should be paid to elements of the physical examination that often are performed incorrectly in obese patients, such as pelvic exams. Gathering this information will allow the clinician to tailor a weight-loss program to each patient individually. Although this represents the most challenging component of obesity care, resources are available to guide the clinician.