Family Practice: A Proposed Solution to the Problem of Meeting the Medical Needs of the Community

Difficulties in meeting today''s community medical needs are outlined, followed by a proposed solution in which the first-contact physician is the trained family physician. The McMaster Family Practice Course is described. The potential research contribution of a Department of Family Medicine is stressed.     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

Do physicians have an ethical obligation to care for patients with AIDS?

This paper responds to the question: Do physicians have an ethical obligation to care for patients with acquired immunodeficiency syndrome (AIDS)? First, the social and political milieu in which this question arises is sampled. Here physicians as well as other members of the community are found declaring an unwillingness to be exposed to people with AIDS. Next, laws, regulations, ethical codes and principles, and the history of the practice of medicine are examined, and the literature as it pertains to these areas is reviewed. The obligation to care for patients with AIDS, however, cannot be located in an orientation to morality defined in rules and codes and an appeal to legalistic fairness. By turning to the orientation to morality that emerges naturally from connection and is defined in caring, the physicians'' ethical obligation to care for patients with AIDS is found. Through an exploration of the writings of modern medical ethicists, it is clear that the purpose of the practice of medicine is healing, which can only be accomplished in relationship to the patient. It is in relationship to patients that the physician has the opportunity for self-realization. In fact, the physician is physician in relationship to patients and only to the extent that he or she acts virtuously by being morally responsible for and to those patients. Not to do so diminishes the physician''s ethical ideal, a vision of the physician as good physician, which has consequences for the physician''s capacity to care and for the practice of medicine.     

Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part II: A Survey

Twenty-six rural California clinics have employed nurse practitioners (NP''s) or physician''s assistants (PA''s) to meet the primary health care needs of local communities. Of the 24 NP''s and 5 PA''s involved, 11 were men and 18 were women. Their average age was 37, and all but five were trained in California. The clinics, with less than 50 percent on-site physician supervision, averaged 19 miles in distance from the nearest physician (ranging up to 63 miles). More than half the clinics were satellites of central, physician-staffed, nonprofit clinics, a third were community-administered and two were private. Half served a whole community, a quarter were established to serve Indians and a quarter to serve Chicanos. Each NP or PA saw an average of 13 patients a day. All nonprivate clinics received subsidies from a variety of local, state and federal funds. Four of the clinics had closed or had no medical staff at the time of our survey.NP/PA clinics are proving to be a feasible and valuable means of offering essential health care needs to remote communities.     

The Physician and Workmen's Compensation—A New Paramedic to Help with Compensation Cases

The first social, no-fault, insurance legislation in California was the Workmen''s Compensation Act of 1911. It has been changed and modified in the years since, and is having an increasing impact on the practice of most California physicians. Many physicians consider caring for the occupationally ill or injured time-consuming and difficult. A newly emerging kind of paramedic, the workmen''s compensation benefit administrator, is available to assist the physician in overcoming difficulties encountered. A cooperative effort between the physician and the benefit administrator will expedite management of industrial patients.     

Informed Consent in California: Latent Liability Without `Negligence'

Informed consent is a legal obligation due from a physician to his patient, an obligation which may not be met by the physician''s skillful treatment of his patient. It may only be met by the treating physician obtaining from his patient knowing authorization for carrying out the intended medical procedure. The physician is required to disclose whatever would be material to his patient''s decision, including the nature and purpose of the procedure, and the risks and alternatives. The disclosures should be made by the physician to his patient, and not through use of consent forms which are not particular to individual patients. To minimize any subsequent claim by the patient that there was a lack of adequate disclosures, the physician should record in the patient''s chart the circumstances of the patient''s consent, and should not rely on the patient''s unreliable ability to recall those circumstances.     

The Neuroanatomical Basis of Panic Disorder and Social Phobia in Schizophrenia: A Voxel Based Morphometric Study

ObjectiveIt is known that there is a high prevalence of certain anxiety disorders among schizophrenic patients, especially panic disorder and social phobia. However, the neural underpinnings of the comorbidity of such anxiety disorders and schizophrenia remain unclear. Our study aims to determine the neuroanatomical basis of the co-occurrence of schizophrenia with panic disorder and social phobia.MethodsVoxel-based morphometry was used in order to examine brain structure and to measure between-group differences, comparing magnetic resonance images of 20 anxious patients, 20 schizophrenic patients, 20 schizophrenic patients with comorbid anxiety, and 20 healthy control subjects.ResultsCompared to the schizophrenic patients, we observed smaller grey-matter volume (GMV) decreases in the dorsolateral prefrontal cortex and precentral gyrus in the schizophrenic-anxiety group. Additionally, the schizophrenic group showed significantly reduced GMV in the dorsolateral prefrontal cortex, precentral gyrus, orbitofrontal cortex, temporal gyrus and angular/inferior parietal gyrus when compared to the control group.ConclusionsOur findings suggest that the comorbidity of schizophrenia with panic disorder and social phobia might be characterized by specific neuroanatomical and clinical alterations that may be related to maladaptive emotion regulation related to anxiety. Even thought our findings need to be replicated, our study suggests that the identification of neural abnormalities involved in anxiety, schizophrenia and schizophrenia-anxiety may lead to an improved diagnosis and management of these conditions.     

Non-accidental injury in children: what we do in Derby.

A scheme for dealing with cases of non-accidental injury in children in the Derby clinical area has been operating since 1971. A stable team of doctors, policemen, and social workers deal with each case. The parents are told at once that battering is suspected, and the police and social services department co-operate closely in establishing the facts, supporting the family, and protecting the child. A psychiatric assessment of the parents may help social workers decide on the long-term care of the child, and the forensic physician is invaluable if the case has to go to court. The team has made three recommendations about prevention and management of these cases: a specialist social service team should be set up to deal with these children and regain the skills and knowledge lost when children''s departments were abolished in 1971; babies should be routinely weighed naked in infant welfare clinics; and juvenile courts should be able to order a psychiatric report on the parents in care proceedings.     

Medical Care of the Alcoholic Patient

Alcoholism is an illness that constitutes a major health problem at all levels of society. The physician should accept his responsibility to prevent it and to care for the alcoholic. If he knows that one of his patients is drinking immoderately, he should warn him of the outlook. A patient''s acquired dependence on alcohol may be overt, or revealed only on examination for organic disease or emotional disturbance. The diagnosis may be accepted reluctantly, or denied despite positive evidence, but the patient should be persuaded to give up drinking. He may require psychiatric help or advice from a social worker. He may be so ill as to require treatment in hospital, and hospitals must recognize the urgency of such admissions. Discharge from hospital does not end treatment, for alcoholism is a chronic disease, requiring long-term planning, persistent follow-up and enduring sympathy by the physician, who must always be as available to his alcoholic patient as he is to his patient with diabetes, epilepsy or cardiac disease.     

The Practitioner and School Age Child Problems

The extraordinary plasticity of the growing child offers the general practitioner an unusual opportunity to intervene either in a preventative or therapeutic manner. Such intervention, properly the task of any informed physician dealing with families, can alter unhealthy growth to healthier development. The whole child is just as important as his medical illnesses; the whole family usually needs help when there is an emotional disturbance in any child.Common problems that lend themselves readily to physician intervention are behavior disorders accompanying a neurological deficit, conduct disorders, enuresis and school phobias. Knowing how to elicit information, to evaluate clinical data and to utilize the findings of a skilled psychologist, and when to refer to a psychiatrist, plus a thorough knowledge of community resources are part and parcel of a physician''s equipment for dealing with children and families.     

The Coordination of Dentists and Physicians in Managing Adverse Oral Effects of Drug Therapy–Report of a Case

Because people are living longer and older people generally use more medications than do the young, it is extremely important that the dentist be aware of the medications that are being taken by his/her patients as well as the reasons for the medications. Frequently, it may be necessary to consult with the patient's physician(s) in order to better understand the patient's medication history. This paper describes a case in which a patient was inappropriately following a long-term course of antibiotic therapy when only a short-term regimen had been intended by the patient's physician. The long-term antibiotic use eventually predisposed the patient to oral candidosis. The dentist contacted the physician and referred the patient back to the physician for an alternative medical regimen. This case report emphasizes that patients may incorrectly interpret physician or dentist instructions concerning medication use. The dentist may be in an excellent position to identify medication errors and should contact the patient's physician whenever in doubt.     

THE HIGH SCHOOL FOOTBALL TEAM PHYSICIAN

Mutual confidence is necessary between the football coach and the team physician. The physician''s decision in the matter of a boy''s condition must always be final. The coach should also consider the physician''s advice in shaping his psychological appeals to the players in before-game and between-halves talks. The physician should be on his way to a man injured on the field as soon as the play is ended. It is up to him and not the trainer or coach to make the diagnosis. The physician must have the ability to make an immediate evaluation of the extent of injury and use appropriate measures to get the player off the field. To see a semi-conscious man with dangling head being half dragged off the field is far worse from the patient''s standpoint and from the spectator''s standpoint than removal by stretcher.     

Adaptation of children to a chronically ill or mentally handicapped sibling.

The presence of a chronically ill or mentally handicapped child in a family can be a stress for the child''s siblings, who often are ill informed about the nature and prognosis of the illness, may be uncertain what is expected of them in the caregiving role, may feel their own identities threatened, and may experience ostracism by their friends and misunderstanding at school. Although individual reactions vary widely, feelings of anger, guilt, resentment and shame are commonly reported. Excessive responsibility and concern about one''s identity may add to these feelings and culminate in psychologic problems in the sibling. The physician caring for the family must be alert for symptoms of emotional disturbance or social maladjustment among the siblings of chronically ill or mentally handicapped children and should be prepared to counsel the family or refer them to a counsellor experienced in this area. In general, the first step is to be sure that the sibling is fully informed about the condition and to encourage frank discussion between the parents and the handicapped child''s siblings.     

Effects of Recruiting Midwives into a Family Physician Program on Women's Awareness and Preference for Mode of Delivery and Caesarean Section Rates in Rural Areas of Kurdistan

BackgroundThe accepted rate rate of caesarean section is 15%. It is expected that an increase in the density of midwives in the family physician program lead to a decrease in this indicator. This study aimed to compare the rates of caesarean section and women''s awareness and preference for mode of delivery before and after the implementation of the family physician program in health centres with and without an increase in midwives density.MethodsIn this cross-sectional study, using multistage cluster sampling method a total of 668 mothers with two-month-old children were selected from among all mothers with two-month-old children who were living in rural areas of Kurdistan province. Using the difference-in-differences model and Matchit statistical model, the factors associated with caesarean section rates and women''s awareness and preference for mode of delivery were compared in centres with and without an increase in midwives density after the implementation of the family physician program. To compare the changes before and after the program, we used the data collected from the same number of women in 2005 as the baseline.ResultsAfter adjusting for baseline data collected in 2005, the resutls showed no significant change in caesarean section rates and women''s awareness and preference for mode of delivery in the centres with and without an increase in midwives density after the implementation of the family physician program. The Matchit model showed a significant mean increase 14%(0.03–0.25) in women’s awareness of the benefits of natural childbirth between 2005 and 2013 in health centres where the density of midwives increased compared with health centres where it did not. The difference-in-differences model showed that the odds ratio of women’s preference for caesarean section decreased by 41% among participants who were aware of the benefits of natural childbirth, (OR = 0.59, 95% CI: (0.22–0.85); P>0.001).ConclusionsThe results of this study showed that an increase in the density of midwives in the family physician program led to an increase in women''s awareness of the benefits of natural childbirth. An increase in women’s awareness of the benefits of natural childbirth was associated with a decreased preference for caesarean section, however this reduction did not have a significant impact on caesarean section rates; possibly, this finding might be attributed to the complexity of this problem that needs a mixed strategy involving various stockholders.     

Problems of the single-parent family unit

Case reports on single-parents families demonstrate some unique problems with which such a family unit must cope. Single mothers frequently present children to the family physician, pediatrician or child psychiatrist with specific symptom complaints. There exists a need to recognize that these symptoms may reflect the special problems of the single-parent family or unresolved issues which led to the formation of the unit.To meet the needs of these parents the physician must explore the specific circumstances of such a family in some depth. Nonjudgmental recognition of their problems may decrease the tendency to view these problems as “psychiatric”. Increased awareness of this entity as a new social unit will help the physician choose proper techniques and appropriate resources to provide support.     

Nurse Practitioner and Physician's Assistant Clinics in Rural California: Part I: Issues

The primary health care needs of at least 26 rural California communities are being served by nurse practitioners (NP''s) or physician''s assistants (PA''s). All of these have physician supervision and support. NP''s and PA''s have proved to be acceptable and effective. With 230 rural areas in California identified as having unmet health care needs, this type of service is likely to increase and should be supported.NP/PA clinics serve total populations or concentrate on Indians, Chicanos or the poor. Many barriers have been overcome, especially over the past four years, to allow these clinics to flourish and increase in number. The availability of nurse practitioners and physician''s assistants has increased due to support to schools and to school policies. Clinic funding has greatly improved; federal funds for general rural clinics, Indians, migrants, family planning and maternalchild health have been greatly supplemented by California state funds. Beginning in 1978, rural NP and PA services can be reimbursed by Medicare and Medi-Cal (California''s Medicaid program).Since 1975 state laws have defined PA and NP roles broadly, and these roles are more precisely defined at the local level. Although nurse practitioners and physician''s assistants generally cannot prescribe or dispense drugs (a major problem in many clinics), demonstration legislation allows special pilot projects to do both. As remaining funding and legal problems are corrected, NP''s and PA''s will serve an even greater role in rural areas.     

Emotional Reactions to Disfigurement from Cancer Therapy

Disfigurement not only produces current anxieties but reactivates childhood conflicts. The emotional reaction depends upon the disturbance to the patient''s major adaptations to life as well as the meaning of the organ to the patient. Fear of isolation and rejection by others may be more terrifying than fear of death. Emotional reactions include regression with marked dependency, anxiety, depression, hostility and, if severe, paranoid states, hypochondriasis, denial, counterphobic behaviour, obsessive-compulsive reactions and schizophrenic reactions. Management basically involves early establishment of a positive doctor-patient relationship. In such a relationship the physican should educate his patient, undercut guilt, accept transient regression and expression of anger, set limits on counterphobic behaviour, either support or gently question denial of reality, and support, without being overly sympathetic, a depressed patient. The nurse, social worker, psychiatrist and the patient''s family may be valuable members of the therapy team. Disfigurements of various body areas pose individual problems of management.     

基于社会公平正义的城市公园绿地空间配置供需关系——以上海徐汇区为例

从社会维度的视角分析评价生态系统所提供的各种效用,必然涉及供需双方。在提供城市公共服务的过程中,城市公园绿地的空间配置会潜在地影响社会效益享用的平等与有效性,是具有显著空间属性的社会资源。研究同时关注城市公园绿地与居住人口(使用者)的空间布局特征,提出基于社会公平正义的生态系统服务供需关系的研究框架,从"地域平等"、"社会公平"与"社会正义"3个层次评估城市公园绿地的空间配置对于社会服务有效供给能力的影响,进而关联使用者需求空间特征分析供需匹配关系。研究构建基于社会公平正义的6个指标反映城市公园绿地社会服务供需状况,并选取上海徐汇区进行实证研究。研究结果表明:(1)徐汇区城市公园绿地存在供需空间不匹配状况,尤其是口袋公园层面存在较大缺口;(2)空间布局均好性较高,地域平等性较好;(3)人均享有绿地资源水平还有待提高,社会公平性不足;(4)进一步地在社会正义层面,评价结果显示过去进行城市公园绿地空间布局决策时并没有特别关注老年人、青少年群体,各个空间单元差距较大,且这两类使用人群密度较高的空间单元在这两个指标上往往低于平均水平,社会正义性亟待提高。研究为实现城市公园绿地空间的社会效益均衡、高效、可持续发展提供了有益的探索。     

The pathogenesis of autism: insights from congenital blindness

There is substantial heterogeneity in the aetiology and clinical presentation of autism. So how do we account for homogeneity in the syndrome? The answer to this question will be critical for any attempt to trace the links between brain pathology and the psychological disabilities that characterize autism. One possibility is that the source of homogeneity in autism is not to be found ''in the child'', but rather in dysfunction of the system constituted by child-in-relation-to-other. We have been exploring this hypothesis through the study of congenitally blind children, among whom features of autism, and the syndrome of autism itself, are strikingly common. To justify such an approach, one needs to establish that the clinical features in blind children have qualities that are indeed ''autistic-like''. We conducted systematic observations of the social interactions of two matched groups of congenitally blind children who do not have autism, rating their social engagement, emotional tone, play and language during three sessions of free play in the school playground. The qualities of social impairment in the more disabled children were similar to those in sighted children with autism. Additional evidence came from independent ratings of the children in a different play setting: on the childhood autism rating scale (CARS), the socially impaired children had ''autistic-like'' abnormalities in both social and non-social domains. If we can determine the way in which congenital blindness predisposes to features of autism, we shall be in a better position to trace the developmental pathways that lead to the syndrome in sighted children.     

Suicide totals for MDs sad reminder of stresses facing medicine,conference told.

A recent conference on physician health cosponsored by the CMA and American Medical Association provided some sobering news. One physician reported on the suicides of physicians practising in the US. Another reported that inroads being made by managed health care is affecting physician morale. "Physicians'' lifetime calling of caring for the sick is being called into question," said Dr. Patricia Tighe. "They have become like factory workers who can''t take pride in their work and are denied a sense of belonging. They are part of a corporate enterprise, to be dispensed with when they are not profitable, and subjected to penalties if their work doesn''t measure up".