Managing uncertainty in family practice.

Because patients present in the early stages of undifferentiated problems, the family physician often faces uncertainty, especially in diagnosis and management. The physician''s uncertainty may be unacceptable to the patient and may lead to inappropriate use of diagnostic procedures. The problem is intensified by the physician''s hospital training, which emphasizes mastery of available knowledge and decision-making based on certainty. Strategies by which a physician may manage uncertainty include (a) a more open doctor-patient relationship, (b) understanding the patient''s reason for attending the office, (c) a thorough assessment of the problem, (d) a commitment to reassessment and (e) appropriate consultation.     

Hypertension in a family practice.

The performance of an urban Canadian family practice in the detection, evaluation, treatment, control and follow-up of hypertension for a 10-year period 1965-74 was reviewed. Vigorous case-finding and treatment were followed by good control of hypertension in 67% of cases and a significant decrease in mortality from stroke and congestive heart failure. It is strongly suggested that the proper location for dealing with hypertension is the primary-care practice and that the general practitioner deserves greater assistance from clinical specialists, health foundations and ministries of health in attacking this problem.     

Computerization of family practice.

The primary focus of computer systems for family practice is on patient billing. Primary care physicians should be aware of the many other benefits that can and should be considered when planning a system for their practice. This article describes the type and extent of information that can be stored in a family practice data base and explores some of the applications in areas of practice and patient management, prevention and research.     

Lifestyle assessment: applying microcomputers in family practice.

A randomised trial of assessment by computer was conducted with 180 patients in a family practice clinic. Histories of alcohol, tobacco, and drug use were obtained by computer (n = 60), interview (n = 60), or self completed questionnaire (n = 60). The results of previous research suggest that some patients may provide more accurate information about "sensitive" problems to a computer. No significant differences, however, in levels of consumption or problems were reported for the three methods of assessment. Patients gave differential ratings about the method of assessment, with the computer rated as more interesting but also more mechanical, cold, and impersonal. Although the interview was initially preferred by most, patients who completed the assessment by computer showed a significant increase (13% to 43%) in their preference for the computer after the assessment. The results of our study indicate that patients'' acceptance of computers in family practice may be favourably influenced by direct experience with a microcomputer.     

The future of family practice training in California.

Although the number of physicians in California has doubled since 1963, the number of family and general practice physicians has declined. The ratio of office-based primary care physicians to population has also decreased. Graduate medical education is funded largely from patient care revenues, but the low rate of reimbursement for ambulatory care makes training in primary care specialties especially dependent on public support. Medicare, the Veterans Administration, and the University of California provide more than $325 million a year in support of graduate medical education in California. Federal and state grant programs provide $5 million a year for family physician training in the state, but appropriations to these programs have been reduced in real terms. California family practice residencies are disproportionately located at county hospitals, where funding shortfalls make them especially vulnerable to cuts in grant programs. Additional resources will be needed if more family physicians are to be trained.     

Radioallergosorbent testing for penicillin allergy in family practice.

OBJECTIVES: To determine (a) the prevalence of patients supposedly allergic to penicillin who have a positive radioallergosorbent test (RAST) result for penicillin G or V and (b) the predictive power of family physicians'' clinical judgement that a patient who is supposedly allergic to penicillin will have a positive RAST result. DESIGN: Prospective multicentre cross-sectional observational study. SETTING: Eleven primary care practices in Newfoundland; 10 were in a rural setting. PATIENTS: Of 110 consecutive adult patients with a supposed allergy to penicillin 97 agreed to participate in the study; 92 underwent RAST. INTERVENTIONS: Patients helped physicians complete a questionnaire and had a venous blood sample taken for the RAST. Physicians examined the clinical history and judged whether the patient was likely to have a positive RAST result. MEAN OUTCOME MEASURES: Rates of positive and negative RAST results for penicillin V and G. RESULTS: Of the 92 patients 8 had a positive RAST result and 84 a negative one. The positive predictive power of a "good" clinical history (e.g., urticaria, swollen eyes, tongue or lips, or an anaphylactic reaction witnessed by a physician) was low (10%); the negative predictive power of a "poor" clinical history (e.g., nausea, vomiting, diarrhea, fever, nonspecific rash or fainting) was 92%. CONCLUSIONS: Less than 10% of primary care patients with a supposed allergy to penicillin will have a positive RAST result. In addition, physicians'' predictions of allergy in such patients are imprecise.     

Walk-in clinics: implications for family practice.

To understand better the reasons for the growth in popularity of walk-in clinics in Canada we surveyed 321 patients with a regular physician in Toronto who attended a walk-in clinic in the same city over a 16-day period in February 1988. They were asked their reason for attending the clinic, their perception of the urgency of their problem, their choices as alternatives to walk-in clinics and their satisfaction and concerns with the type of care received at the clinic. The three most common reasons for attending the clinic were convenient location (in 33% of the cases), inability to see their regular physician soon enough (in 16%) and no appointment needed (in 13%). Most (80%) of the patients felt that they needed medical attention within 24 hours after the onset of their problem. Most (83%) of the respondents would have sought medical attention at another walk-in clinic, from their regular physician or at an emergency department had the clinic been closed. Only 36% and 18% of the patients respectively responded that their regular physician worked evenings or weekends. Most of the visits to the clinic were outside regular weekday business hours. The level of satisfaction with the service received at the clinic was high. The extended hours and no-appointment philosophy of walk-in clinics, coupled with family physicians'' reluctance to work evenings and weekends, have made such clinics an attractive option for patients with primary care problems that they believe require prompt attention.     

Management of childhood urinary tract infection in family practice.

To find out to what extent doctors appreciate the potential damage that bacteriuria may cause, we sent questionnaires to 195 family practitioners and trainees in one health board in Northern Ireland. The results of the survey showed that, though doctors seemed to be aware of the risk of renal disease, this was not reflected in practice.