A headache at the end of the day

This essay presents a family medicine office visit with a child and both parents; details have been modified to protect patient and physician confidentiality. A child's headache, which has gone away before the start of the office visit, provides a window into the relationship between the parents and into the sources of their worries about their child's health. The essay highlights the multiple medical and behavioral concerns that the physician must keep in mind during relatively brief office encounters, and the intellectual challenge of maintaining appropriate attention to all these threads, and understanding their interactions, while completing the visit in a timely fashion.

Prescription for health: changing primary care practice to foster healthy behaviors

PURPOSE

The leading causes of premature death in the United States are linked to 4 behaviors: smoking, unhealthy diet, physical inactivity, and risky alcohol use. We report lessons from 17 exploratory projects funded under Prescription for Health that tested the feasibility of innovative behavior change strategies for at least 2 of these behaviors in primary care practices.

METHODS

Seventeen practice-based research networks (PBRNs) implemented and evaluated tools, cues, and techniques in 120 family medicine, internal medicine, pediatric, and nursing practices across an ethnically diverse sample of adults, children, and adolescents in rural and urban settings. We reviewed progress reports and notes from site visits and 3 meetings to generate overarching lessons.

RESULTS

PBRNs successfully implemented their projects in diverse practices despite reported logistical challenges and practice constraints. The networks showed that distributing the effort across the care team and throughout the practice and community is possible. Although each behavior required specific attention, each did not require its own separate staff and system. Three models emerged as helpful guides for the comprehensive redesign of health behavior counseling, but they require adaptation for use in real-world primary care settings. Traditional methods of collaboration yielded mixed results, making obvious a need for dedicated collaboration funds and a better framework to identify and align high-yield opportunities.

CONCLUSIONS

These projects confirm the feasibility of health behavior counseling in primary care practice. They also highlight the need for substantive practice redesign, and the value of models and frameworks to guide redesign and collaborative efforts.

Who first suggests the diagnosis of attention-deficit/hyperactivity disorder?

PURPOSE

We wanted to survey physicians in the Washington, DC, metropolitan area regarding the frequency with which physicians, teachers, parents, and others first suggest the diagnosis of attention-deficit/hyperactivity disorder (ADHD).

METHODS

A questionnaire was mailed to all family physicians, primary care pediatricians, and child psychiatrists in greater Washington, DC. In answer to the question, "Who first suggests the diagnosis of ADHD?" respondents assigned percentages to primary care physicians, consultants, parents, teachers, etc.

RESULTS

Teachers were most likely to be first to suggest the diagnosis of ADHD (46.4%; 95% CI, 44.1%-48.7%), followed by parents (30.2%; 95% CI, 28.3%-32.0%), primary care physicians (11.3%; 95% CI, 9.7%-12.8%), school personnel other than teachers (6.0%; 95% CI, 4.9%-7.2%), consultants such as child psychiatrists or psychologists (3.1%; 95% CI, 2.3%-3.9%) and other specified categories (3.0%; 95% CI, 2.4%-3.6%).

CONCLUSIONS

Teachers and other school personnel are often the first to suggest the diagnosis of ADHD in children in the greater Washington, DC, area. Regional variations in the prescribing of medication for ADHD may be caused at least in part by variations in the likelihood of a teacher suggesting the diagnosis of ADHD.