Obstetrics in family practice in the state of Ohio

Two hundred eighty-two active members of the Ohio Academy of Family Physicians responded to a survey questionnaire regarding the content of obstetrics in their practices. Factors that may influence physicians to discontinue obstetrics were also evaluated. Sixty respondents (21 percent) were performing vaginal deliveries in 1987. Only 45 (16 percent) planned to continue delivering babies beyond 1989. Family physicians who started practice within the past seven years were less likely to include obstetrics in their first year of practice than those who began practice prior to 1980. To those physicians who have eliminated obstetrics from their practice in the past five years, fear of litigation and increasing malpractice insurance costs were significantly more important issues than to their colleagues who had stopped doing obstetrics prior to 1976. Every year fewer family physicians choose to provide care to their obstetric patients. The results of this study suggest that only with changes in the medicolegal and liability environments will obstetrics continue to be a part of family practice in Ohio.     

The effect of malpractice insurance costs on family physicians' hospital practices

One hundred fifty-two family physicians responded to a questionnaire about malpractice insurance from the Arizona Academy of Family Physicians. Physicians were asked whether they had limited their hospital privileges, by choice, because of the cost of malpractice insurance. One hundred thirty-eight (90.8 percent) of the physicians had a hospital practice. Of these, 36 (26.1 percent) reported that they had restricted their hospital practice because of the cost of insurance. Most commonly, restricted activities involved the discontinuation (38.7 percent of the 36 physicians) or limitation (22.2 percent) of obstetrical activities. Other physicians had eliminated general abdominal surgery (24.9 percent) and other surgical and radiologic procedures. The tendency of family physicians to limit their practices because of the cost of insurance premiums has important implications for health care in rural areas. It also may affect the scope and practice patterns of family physicians and other primary care physicians.     

德国家庭医生执业路径及服务模式

德国“家庭医生”包含全科医生、家庭内科医生和儿科医生三类医师。除门诊开业外,家庭医生执业场所可延伸至医院,医院通过加强私人诊所与医院之间的良好互动从而发展整合医疗。家庭医师协会作为家庭医生职业群体代理,在福利报酬等方面与政府医保支付机构进行谈判。“家庭医生服务模式”下,疾病保险基金通过改进与家庭医生的服务购买协议,从而达到激励患者和服务提供方主动依从“守门人”制度的效果。     

Trial of rural practice evaluation: mutual rotation by family physicians

OBJECTIVES: We aimed to investigate the usefulness of mutual rotation by family physicians in providing an evaluation of rural medical practices. METHODS: Between June and October 1994, each of four family physicians rotated to the practices of the other three, where they worked as a transient locum for 4-5 days and evaluated each practice. They were field faculty physicians of the Department of Community and Family Medicine, Jichi Medical School, and based at general practices accredited for undergraduate and postgraduate training. Two school- based faculty physicians also participated in the study as spare members. RESULTS: The rotation was conducted four times to complete the mutual rotation programme. There was some difference in evaluation among the practices, which indicated the characteristics of the practices. The evaluation accorded relatively well among the participants. CONCLUSIONS: Mutual rotation by family physicians provides an objective and practicable evaluation of general practices and contribute to upholding their quality, which is crucial to medical education.      

Obstetric care among family physicians in Pennsylvania. Trends, association with residency training, and policy implications

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.     

Community medicine in the training of family physicians.

Family practice residency programs are encouraged to include community medicine training in their curriculum, but there is little agreement as to what community medicine is or what would constitute appropriate training. Community medicine is most commonly defined as a discipline concerned with the identification and solution of health care problems of communities or other defined populations. The inclusion of training experiences in the identification and solution of health care problems of communities has two basic advantages for family practice residency programs: it fosters a contextual approach in the care of individual patients and it builds knowledge and skills for those who will work with communities in future practices. An example of curricular content is included. A survey was conducted in order to determine what residency programs teach in the field of community medicine. The results show that few of the responding programs include the areas which most clearly relate to community medicine. It is hoped that the report of these results, the rationale presented for including community medicine in the training of family physicians, and the suggested outline of curricular content will further encourage and assist family practice residency programs to incorporate such training in their curricula.     

Care of the elderly patient with lower extremity amputation

BACKGROUND: The elderly patient with a lower extremity amputation (LEA) remains relatively common in most family medicine practices. LEA can be categorized into three major types: partial foot, transtibial amputation, and transfemoral amputation. Family physicians have not been well trained to provide care to these patients. METHODS: A literature review was performed using the key words "lower extremity amputation," "aged" and "rehabilitation." RESULTS AND CONCLUSIONS: Appropriate medical, surgical, and rehabilitative care can have a positive effect on the functional outcome for an elderly patient with a lower extremity amputation. The family physician can be instrumental in preparing the patient and family for surgery, providing psychological support, preventing and treating complications, managing comorbid illness, and assisting in rehabilitation. In addition, the family physician is primarily responsible for the daily care needs of these patients.     

Obstetric privileges for family physicians: a national study

In 1988 the American Academy of Family Physicians sampled 4400 active members whose mailing address was in one of the 50 states or the District of Columbia. The sample was stratified by nine census regions; after two mailings a 76.2% response rate was achieved. Nine in ten active members have hospital admission privileges. A higher proportion of family physicians in the West North Central census region have privileges at various levels of obstetric care than in other census regions. For those family physicians who do not have privileges for any obstetrics, most indicated that they chose not to include obstetric care in their hospital practices. Family physicians most likely to have obstetric privileges include those who practice in nonmetropolitan areas and those who have completed a family practice residency program. Although disparities in the proportion of family physicians with certain hospital privileges exist among regions, the majority in each region indicated that the privileges afforded them were appropriate.     

The physician as manager. "What" and HOW" OF PRACTICE MANAGEMENT EDUCATION.

Management science and application play a pivotal role in preparing physicians for effective and efficient office practice. Integration of management theory into practice management education of family physicians may be accomplished by developing and maintaining a well-organized model practice, involving residents directly in management decisions and problem solving, using a variety of resource people in and outside the model unit, and providing quantitative analysis of practice performance. After three years of development, the Family Practice Center of Akron City Hospital has instituted a practice management curriculum whereby residents become actively involved in the management and supervision of the model practice, conduct research study into management problems, and receive training and supervision as they develop leadership and organizational skills.     

Pediatric emergencies in the office: are family physicians as prepared as pediatricians?

OBJECTIVE: Our objective was to assess the occurrence of pediatric emergencies in the offices of family physicians and pediatricians, the preparedness to respond, and the perceived importance of being prepared. STUDY DESIGN: We performed a cross-sectional random mail survey of physicians. POPULATION: Surveys were sent to 187 family physicians and 129 pediatricians practicing in North Carolina with 75% and 86% response rates, respectively. The 169 total respondents were in community practices regularly treating children and were included for analysis. OUTCOMES MEASURED: We measured the incidence of 8 types of pediatric emergencies, the availability of 11 items for resuscitation and stabilization, whether the physician had Pediatric Advanced Life Support (PALS) training in the previous 2 years, whether the office ever conducted a mock emergency, and beliefs about the importance of preparing for and providing emergency care to children. RESULTS: Six types of pediatric emergencies were seen in one third or more of all practices during the year. The average practice saw 4 or more pediatric emergencies in a year (family physicians = 3.8 vs pediatricians = 4.9, P <.001). Family physicians had fewer resuscitation and stabilization items than pediatricians (5.7 vs 8.6 items, P <.001) and were less prepared in terms of PALS training (19% vs 51%, P <.001). Those with PALS training were more likely to have an intraosseous needle and Broselow tape and to have conducted a mock code. Family physicians considered it is less important than pediatricians to provide such care or to be prepared to do so. CONCLUSIONS: Pediatric emergencies in the office are likely for either specialty. Family physicians may be less prepared, and they discount the importance of the problem and need for preparation.     

Practice style differences between family physicians and internists.

BACKGROUND: Because an estimated 70 percent of all medical care expenditures are generated by physicians, evaluation of specialty practice styles is essential to learn what changes in policies governing physician training, service delivery, and patterns of medical practice would promote cost containment. METHODS: We examined the 1981 and 1985 National Ambulatory Medical Care Survey for seven primary care diagnoses to compare practice style differences between family physicians and internists and to look for changes in family physicians' practice styles between 1981 and 1985. RESULTS: Family physicians referred fewer patients in 1985 and spent 3 to 10.5 minutes less per patient encounter than internists. Clinical laboratory testing, electrocardiogram (ECG) ordering, and radiographic examinations differed significantly between the two groups in 1981 and 1985 for some diagnoses. In 1981, family physicians did Papanicolaou smears 2.2 times more often than internists during general medical examinations; however, in 1985, there was no difference. Between 1981 and 1985, family physicians ordered significantly more laboratory tests and ECGs for some diagnoses but had no change in the number of radiographs ordered or referrals. For six diagnoses, they spent more time with a patient encounter in 1985 than in 1981. CONCLUSIONS: Family physicians and internists appear to be more alike in practice style, but significant differences remain. These differences, as well as changing practice styles of family physicians, have implications for training and health care resource distribution.     

Styles of care provided to children in the United States: a comparison by physician specialty

This study was based on findings from a national survey of physicians that was conducted from 1975 to 1977. The data concern face-to-face encounters with children in the ambulatory care setting. Over one half of the practices of pediatricians consisted of infants and preschoolers, whereas well over 50 percent of the child patients of other types of physicians were 10 to 19 years old. The proportion of visits dealing with a problem already under care was consistently greater for specialists other than primary care physicians; the proportion of visits for preventive care was much lower in the practices of these specialists than in primary care practice. These findings suggest that other specialists are functioning in ways different from primary care physicians. As compared with family physicians, pediatricians performed more diagnostic tests for all diagnoses and more immunizations and counseling about growth and development, were more likely to have seen children previously for problems other than the one dealt with in the visit under consideration, and were more likely to report that no specific therapy was required (except for well-child care). However, family physicians did more counseling about family and sex matters than pediatricians, were much more likely to have seen musculoskeletal and skin problems among 10- to 19-year-old patients, and were much more likely to have administered cauterization, cryotherapy, or suturing for skin problems. Family physicians provided more counseling of all types and did more minor surgical procedures than general practitioners. These and other findings show the existence of systematic differences across specialties in the care of children, even for apparently similar problems.     

Physician attitudes and behavior in response to changes in Medicare reimbursement policies

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.     

Family practice residencies in community health centers--an approach to cost and access concerns.

An inadequate number of trained primary care clinicians limits access to care at Community Health Centers. If family practice residents working in these centers can provide care to patients at a cost that is comparable to the center''s hiring its own physicians, then expansion of Family Practice Residency Programs into community centers can address both cost and access concerns. A cost-benefit analysis of the Family Practice Residency Program at the Fresno, CA, community center was performed; the community center is affiliated with the University of California at San Francisco. Costs included (a) residents'' salaries, (b) supervision of the family practice residents, (c) family practice program costs for educational activities apart from supervision at the community center, and (d) administrative costs attributable to family practice residents in the community center. Benefits were based on the number of patients that residents saw in the community center. Using this approach, a cost of $7,700 per resident per year was calculated. This cost is modest compared with the cost of training residents in inpatient settings. The added costs attributable to training residents in community health centers can be shared with agencies that are concerned with medical education, providing physicians to underserved communities, and increasing the supply of primary care physicians. Redirecting graduate medical education funding from hospitals to selected ambulatory care training centers of excellence would facilitate placing residents in community centers. This change would have the dual advantage of addressing the current imbalance between training in ambulatory care and hospital sites and increasing the capacity of community health centers to meet the health care needs of underserved populations.     

Extending the boundaries of family medicine to perform manual procedures

A recent survey by Menahem and colleagues revealed that 65% of the surveyed primary care physicians reported that they performed any minor surgical procedures, and 46% reported performance of any musculoskeletal injections. Lack of allocated time and lack of training were the main reported barriers confronting higher performance rates.Healthcare systems are shifting large chunks of traditional hospital-centered activities to competent and comprehensive community-based structures. These changes are very well aligned with key trends in modern consumerism that prefer a close to home availability of medical services.Minor surgical procedures and musculoskeletal injections are good examples of medical activities that had been performed mainly by hospital and community based specialists. The syllabus of specialty training in Family Medicine in Israel includes these skills and trainees should acquire them during the residency program. We estimate that hundreds of family physicians obtain different levels of such training. Yet, only few family physicians have allocated protected time for performance of the procedures.For the skilled physician, performance of such relatively simple procedures extends his professional boundaries and the comprehensiveness of his service. For the healthcare system the “extra effort” and investment needed for performance of minor surgical procedures in primary care clinics is small.The results of the present study reflect on wider issues of care delivery. This study highlights the need for formalized and documented training of family physicians together with allocation of managerial and technical requirements needed to encourage these and similar medically and economically justified endeavors that seem to be perfectly aligned with the wishes of healthcare consumers.     

A Strategy to Increase the Number of Urban Family Practice Resident Physicians Who Enter Rural Practice

Physician geographic maldistribution is a problem in the United States health care system. Innovative strategies are needed to entice resident family physicians training in the larger, more numerous suburban and urban training programs to practice in rural areas upon completing their training. This paper describes a strategy used at St. Elizabeth Medical Center Family Practice Residency Program, Dayton, OH, to encourage rural practice. In the St. Elizabeth plan, the interested family practice resident moonlights in a rural practice provided by the local county hospital. The county medical staff covers the resident physician's practice during the frequent absences. The residency program faculty provide on-site supervision, telephone back-up coverage, and practice consultation. The county hospital provides billing services; the resident physician retains 100 percent of collections. The resident physician gains exposure to the knowledge, skills, and attitudes needed in rural practice. Upon completion of residency training, the physician remains in practice and is not required to pay back any expenses incurred by the hospital. Two resident physicians participate currently; three others have expressed interest in practicing in the community. A similar plan might work in parts of the United States where, like Ohio, training programs and rural communities are not far apart.     

Informed consent: law, clinical reality, and the role of the family physician.

Informed consent is typically seen as most relevant to surgical and other invasive specialties. Although family physicians perform fewer high-risk procedures, they are nonetheless extensively involved in the informed consent process because of the comprehensive and continuing nature of the family physician-patient relationship. Family physicians have a particularly important role in helping their patients to understand what diagnostic or therapeutic alternatives are available. Family physicians have an independent role in the informed consent process, as well as a collaborative role in the context of consultation and referral. Legal rules that require disclosure of alternatives to the patient by the treating physician are examined in the context of the family physician's role as a coordinator of patient care. Practical suggestions regarding discussion of alternatives, extent of disclosure, coordination with consulting physicians, and encouragement of patients' participation in discussions are offered.     

The Montana Model: Integrated Primary Care and Behavioral Health in a Family Practice Residency Program

To address the local health care needs of both patients and primary care providers in Montana, an integrated primary care and behavioral health family practice clinic was developed. In this paper we describe our experience with integrating mental health and substance abuse services into a primary care setting (a community health center) while simultaneously teaching family practice physicians to take the lead in providing these services. The Deering Community Health Center in Billings, Montana, is a Federally Qualified Health Center serving a largely low-income patient population. The medical care at the clinic is provided primarily by the faculty and residents of the Montana Family Medicine Residency. The teaching model was founded on the belief that improved care will result when physicians have increased comfort with, and are able to enjoy the challenges of, patients with mental illnesses. The enhanced longitudinal curriculum incorporates mental health across the 3 years of the family practice residency. Unique characteristics of this model include staffing and the concurrent delivery of a high volume mental health service while teaching family practice resident physicians and the faculty to integrate this competency into their primary care practices.     

Family Physicians in the Maternity Care Workforce: Factors Influencing Declining Trends

Family physicians provide access to maternity care for a disproportionate share of rural and urban underserved communities. This paper aims to determine trends in maternity care provision by family physicians and the characteristics of family physicians that provide maternity care. We used American Board of Family Medicine survey data collected from every family physician during application for the Maintenance of Certification Examination to determine the percentage of family physicians that provided maternity care from 2000 to 2010. Using a cross-sectional study design, logistic regression analysis was performed to examine association between maternity care provision and various physician demographic and practice characteristics. Maternity care provision by family physicians declined from 23.3 % in 2000 to 9.7 % in 2010 (p < 0.0001). Family physicians who were female, younger and US medical graduates were more likely to practice maternity care. Practicing in a rural setting (OR = 2.2; 95 % CL 2.1–2.4), an educational setting (OR = 6.4; 95 % CL 5.7–7.1) and in either the Midwest (OR = 2.6; 95 % CL 2.3–2.9) or West (OR = 2.3; 95 % CL 2.1–2.6) were the strongest predictors of higher likelihood of providing maternity care. While family physicians continue to play an important role in providing maternity care in many parts of the United States, the steep decline in the percentage of family physicians providing maternity care is concerning. Formal collaborations with midwives and obstetrician-gynecologists, malpractice reform, payment changes and graduate medical education innovations are potential avenues to explore to ensure access to maternity care.     

Training and application of community-oriented primary care (COPC) through family medicine in Catalonia, Spain

The community-oriented primary care (COPC) approach, implemented in various countries by family physicians, general practitioners, and other primary care workers, integrates clinical medicine with aspects of public health. A process of 20 years of training health professionals (40-hour workshop) by the professional association of family physicians (Catalan Society of Family and Community Medicine), training family medicine residents and giving support to health teams in Catalonia, Spain, generated a present group of 30 primary care teams involved in community health projects. This paper describes and analyzes factors related to changes in the health system, the role of family medicine in Spain, and to features of the COPC approach and its training methods as elements that narrow the gap between training and practice.