Doctor-patient discussions of alternative medicine for back pain

OBJECTIVE

To document the frequency of conversations about alternative medicine during primary care consultations for back pain in diverse settings.

DESIGN

"Exit interview" type patient survey.

SETTINGS

General practices in Seattle, Washington; rural Israel; and Birmingham, England.

PATIENTS

A convenience sample of 218 adults completing a doctor visit for back pain.

MAIN OUTCOME MEASURES

Frequencies of doctor-patient discussions of alternative medicine.

RESULTS

Alternative medicine was discussed in a minority of visits (US site 40%, Israel site 37%, UK site 14%, p < 0.05). At each site, patients initiated at least half of the discussions. Users were five to six times more likely to discuss alternative medicine with their doctor than non-users (p < 0.05 for comparison at each site). The percentage of patients who used alternative medicine but left the consultation without discussing it was similar at all sites (US site 17%, Israel site 23%, UK site 15%).

CONCLUSIONS

Discussions of alternative medicine occurred in a minority of consultations for back pain although the rate varied considerably by site. Discussions were initiated primarily by patients who use it.

Improving continuity by increasing clinic frequency in a residency setting

BACKGROUND AND OBJECTIVES

Continuity of care is required in family practice training programs. However, continuity for some patients may not be adequately served in the traditional training model that has residents in the family practice center (FPC) for 1 to 3 half-day clinics per week. This study sought to determine if increasing clinic frequency in a family practice residency has an effect on continuity of care.

METHODS

On January 1, 1999, the residency program changedfrom a traditional clinic scheduling model to one where all residents saw patients in the FPC 4 to 5 days a week. By using shorter clinic sessions, total resident time in the FPC was nearly unchanged (decreasing 5% overall). We reviewed 1,709 randomly selected billing records for residents' patients who frequently utilized medical care (three or more visits within 6 months) and assessed continuity for 1 year before and after this intervention, using both the modified, modified continuity index (MMCI) and the percentage of visits to the primary care provider (PCP).

RESULTS

Overall, the MMCIfor patients who frequently saw residents increasedfrom .59 to .64. The average frequency with which these patients saw their PCPs improvedfor the first-year class (from 51% of visits before implementation to 72% after) and the third-year class (from 66% of visits to 72%).

CONCLUSIONS

Scheduling daily resident clinics in the FPC increased continuity among patients who frequently saw residents beyond that achieved using traditional scheduling, without increasing total resident time in the FPC.

Evaluating family practice residencies: a new method for qualitative assessment

BACKGROUND AND OBJECTIVES

This study reports on a novel qualitative method for evaluating family practice training programs. Previous evaluation techniques have generally been quantitative in nature and have limited their scope to a few isolated elements of residency education.

METHODS

A guest faculty, working in conjunction with local faculty, conducted a site analysis of an East Coast and a West Coast family practice residency. Multiple qualitative techniques were used, including participant observation, focus groups, long interviews, and analysis of key texts. Program strengths and weaknesses were analyzed, and a discrepancy model was used to compare program goals and ideals to the actual training realities. The analysis used a process of immersion/crystallization, and triangulation of the multiple data sources was achieved through repeated comparisons.

RESULTS

This report focuses on the process of the evaluations, rather than on their content. In general, the sites have achieved most of their objectives, but notable limitations are present at both programs. This is particularly apparent in terms of multiple demands on faculty, the lack of a shared vision, and program isolation.

CONCLUSIONS

Significant lessons were learned from these initial assessments, which can be used to further refine the method. Comprehensive qualitative reviews may provide unexpected insights and identify program limitations and strengths.

Teaching tips for clinical faculty from the Zen tradition

BACKGROUND AND OBJECTIVES

Teachers of family medicine may improve their skills by examining teachers from other disciplines and cultures. The teaching traditions of Zen might be adapted to medical education. Zen teachers work to eliminate restrictive preconceptions about themselves, their teaching roles, and their students. They strive to encounter their students with their minds and their perceptions clear and to remain ever open to moments of spontaneity and creativity. Examples of how these principles may be used in medical education are presented.

Referrals for alternative therapies

BACKGROUND

The purpose of this study was to examine how allopathic physicians participate in the decision to refer patients for alternative therapies.

METHODS

A pretested, self-administered, structured questionnaire was distributed simultaneously to all area physicians at community locations in Washington State, New Mexico, and southern Israel. The primary outcome measures were monthly and yearly rates of referral to alternative therapies.

RESULTS

More than 60% of all physicians made referrals to alternative providers at least once in the preceding year and 38% in the preceding month. Referrals were generally based on patient requests, synergy between the alternative therapy and the patients' cultural beliefs, failure of conventional treatment, and the belief that patients have "nonorganic" or "psychological" disease. There was no relationship between the rate of referral and the referring physician's level of knowledge about, beliefs about the effectiveness of, or familiarity with alternative therapies.

CONCLUSIONS

Primary care physicians are more likely than other medical specialists to be knowledgeable about, personally subscribe to, and refer patients for alternative therapies. Physicians who use alternative techniques for themselves and their families or who adopt complementary therapies into their practices have higher rates of referrals. Referral rates and patterns were similar between sites despite considerable cross-cultural and health system differences. Given the high rate of referral and the absence of an apparent internal logic for such recommendations, guidelines and physician education may be advisable.

A clinical approach to alternative medicine

Our patients receive and will continue to receive alternative therapies regardless of our stand on the issue. While scientific scrutiny may slowly bring a few of them into the medical mainstream, the number of alternative techniques is unlikely to dwindle significantly. Primary care physicians can help their patients deal with them by knowing the local alternative medical community, by gentle counseling about the potential for harm in certain techniques, and by steering patients toward practitioners with a reasonable scope of practice that matches the patient's belief system. In this way, the physician may confidently support the patient's belief in the healing power of whatever therapy--alternative or traditional--is chosen.

Health effects of outdoor air pollution

One hundred sixty-four million Americans live in areas that fail to meet the National Ambient Air Quality Standards for six common air pollutants: particulates, sulfur dioxide, carbon monoxide, nitrogen dioxide, ozone and lead. The impact of these pollutants on health is significant. A Pollutant Standards Index (PSI) ranging from 0 to 500 is used to monitor air quality. When the PSI exceeds 100, the acceptable federal standard has been exceeded by at least one of four measured pollutants. When this occurs, all individuals should be advised to curtail physical activity between late morning and sunset and to remain indoors if possible. Athletes should be encouraged to train in the early morning, when photochemicals are usually at their lowest levels.

A five-step "microskills" model of clinical teaching

Teaching family practice residents in a clinical setting is a complex and challenging endeavor, especially for community family physicians teaching part-time and junior faculty members beginning their academic careers. We present a five-step model of clinical teaching that utilizes simple, discrete teaching behaviors or "microskills." The five microskills that make up the model are (1) get a commitment, (2) probe for supporting evidence, (3) teach general rules, (4) reinforce what was done right, and (5) correct mistakes. The microskills are easy to learn and can be readily used as a framework for most clinical teaching encounters. The model has been well received by both community family physicians interested in teaching and newer residency faculty members.

A developmental model of ethnosensitivity in family practice training

Cross-cultural medicine is a natural and important part of family practice. Unfortunately, its acceptance and implementation into family practice training programs has been limited. This paper presents a developmental model of ethnosensitivity in family practice training which assesses a trainee's ability to grasp cross-cultural issues and suggests strategies for improving cross-cultural communication and practice skills.