Biomedical subjects
R A Fried
Publications and source records attributed to R A Fried.
Preventing cervical cancer: the role of the Bethesda system.
The Papanicolaou smear is a well-established component of preventive health protocols for women. The purpose of this screening tool is to detect precursor lesions of invasive cervical carcinoma; however, the natural progression of these lesions is unclear, and it currently is not possible to determine which of the many dysplastic findings have carcinogenic potential. Furthermore, disagreement exists concerning the time frame for the malignant transformation of dysplastic cervical lesions. Despite these concerns, cervical screening has been credited with reducing morbidity and mortality from invasive cervical carcinoma in certain populations, and almost all family physicians provide this service to their female patients. The Bethesda system of cytopathologic reporting (introduced in 1988 and revised in 1991) is designed to improve communication between pathologists and clinicians. Compared with other taxonomies, the Bethesda system allows for distinction between changes associated with inflammation and infection and those reflecting squamous cell atypia and dysplasia.
The use of objective measures of asthma severity in primary care: a report from ASPN.
BACKGROUND: The rising incidence of and mortality from asthma have prompted the development of practice guidelines for diagnosis and management. A cornerstone of these guidelines is the use of objective measures of asthma severity: spirometry or peak expiratory flow rates. We studied the extent to which primary care clinicians used objective measures of asthma severity. METHODS: Practices affiliated with the Ambulatory Sentinel Practice Network in the United States and Canada collected data on 490 asthma-related encounters involving 439 patients. For each encounter, the practice recorded the availability of the results of spirometry, peak expiratory flow rates, oxygenation (arterial blood gas or pulse oximetry), and chest radiograph to the clinician. RESULTS: Objective data about asthma severity were infrequently available to ASPN clinicians at the time of the encounter. In 67.8% of encounters, there was no current or past spirometry result, in 55.1% there was no current or past peak flow measurement, and in 74.3% there was no current or past determination of oxygenation. Chest radiographs, on the other hand, were available for most (64.7%) patients. The lack of objective measures was not related to lack of access to the relevant technologies. Most practices noted easy access to spirometry (72.2% of practices), peak flow meters (72.2%), oxygenation determination (61.1%), and radiography (83.3%). CONCLUSIONS: In this study, most primary care clinicians did not have objective data about the severity of their patients' asthma at the time of the encounter. This relative lack of objective data was not explained by lack of access to the relevant technology for determining severity. It may instead reflect the opinion of primary care physicians that such information is not necessary in the care of these patients.
Carpal tunnel syndrome in primary care: a report from ASPN. Ambulatory Sentinel Practice Network.
BACKGROUND: Carpal tunnel syndrome (CTS) is a common condition in primary care, yet little is known about its presentation and management. This study was designed to provide a better understanding of the frequency of CTS in a primary care population, and its presentation, diagnosis, and management. METHODS: Clinicians in 74 Ambulatory Sentinel Practice Network (ASPN) practices from 30 states and three Canadian provinces collected data on all patients presenting with symptoms of CTS during a 30-month period. RESULTS: The adjusted frequencies of all visits and of first visits for symptoms of CTS were 1.01 and 0.68 per 1000 patient visits, respectively. Women visited more frequently than men with new onset symptoms of CTS (0.81 vs 0.55 per 1000 visits), and homemakers accounted for 15.9% of all new cases. Clinicians judged 43.1% of all CTS incident visits to be job-related. The diagnostic evaluation of patients seldom included nerve conduction studies (12.9%) or electromyography (11.8%). The most frequent treatments were splints (56.3%) and nonsteroidal anti-inflammatory agents (50.8%). Four-month follow-up data were obtained for 68.5% of the patients, and symptom relief was reported by 55.2% of patients. Ninety percent of patients were able to continue working at the same job, and 96% were able to continue their usual activities. CONCLUSIONS: Carpal tunnel syndrome symptoms are common in primary care, and most cases occur among women, many of whom are homemakers. Most patients with CTS symptoms are treated conservatively by their primary care clinicians with minimal testing or referral, and most patients report improvement or resolution of symptoms at 4 months.
The dentist and preventive medicine: be all that you can be.
Explore the source record for details and available documents.
The family physician and health objectives for the nation.
Specific, measurable health objectives for the nation have helped guide federal, state, and local policy in disease prevention and health promotion during the 1980s. About one half of these objectives will probably be achieved by 1990. Public awareness of hypertension and its consequences, for example, is at very high levels. Although the physician's office is a key setting for accomplishing many of the objectives, physicians remain largely uninformed about them and uninvolved in the broader process of public health policy formulation. Family medicine, as a specialty concerned about the care of the individual in the context of family and community, has much to contribute to future public health planning efforts. A plan for drafting the year 2000 objectives is beginning. Because the objectives will help shape health policy in the future, family physicians should be involved in developing appropriate health objectives for the nation and helping to implement them.
Cerebral cysticercosis of the fourth ventricle: a problem in primary care diagnosis.
Explore the source record for details and available documents.
Prevention in medical education: an uncertain future.
There is reason for pessimism about the incorporation of prevention into medical education. In addition to what might be called the standard reasons for resistance to prevention, there are at least three other structural barriers: the destabilization of the health care system, the loss of interest in careers in primary care, and preventive medicine's failure to adopt a far-reaching critique of medicine and medical education. Only through linkages to progressive health care reform, to primary care, and to the biopsychosocial model can prevention achieve an important place in medical education.
Impact of a comprehensive health promotion curriculum on physician behavior and attitudes.
Physician involvement with health promotion and disease prevention (HP/DP) is essential in the control of diseases in which behavioral risk factors are etiologically important. Yet physician involvement with health promotion is generally perceived as less than optimal. We report that an intensive, multifactorial curriculum introduced into a community hospital family medicine residency program increased physicians' use of preventive strategies with their patients and facilitated their use of specific, easy-to-follow protocols for the management of common problems amenable to health promotion.
The family physician looks at occupational health information.
Although much is known about occupational and environmental health risks, this information is rarely used by physicians practicing primary-care medicine. As a specialty with roots in the epidemiologic tradition, family medicine should be able to use these data to help care for the individual in the context of the family and community. In this discussion, the historical links between family medicine and epidemiology are reviewed, barriers to the use of epidemiologically derived occupational health information are analyzed, and solutions to the problem of integration are proposed. The relationship between primary care and occupational medicine is a subset of the relationship of clinical practice to epidemiology in general.
Developing a marketing plan for a residency practice.
Competition for patients is becoming a hallmark of the health care system. Family medicine centers must increasingly think about marketing if they are to attract and retain adequate numbers of patients for resident education. As we have learned from direct experience, marketing is best done in the context of a comprehensive plan. We believe residency faculty can develop and successfully implement marketing plans. Since 1982, we have developed and implemented a marketing plan for the Mercy Family Medicine Center located in Denver, Colorado. We describe the planning process we employed and briefly discuss the successful results due to the plan's implementation.
Appropriateness of hospital use by family physicians.
BACKGROUND: Reducing inappropriate hospital admissions could lead to lower total health care costs without compromising the quality of care. Research suggests that a sizeable portion of hospital admissions are inappropriate. Other studies indicate that family physicians use health care resources, including hospitalizations, less often than other primary care physicians. To gain additional insight into family physicians' decisions to admit patients, we performed an exploratory study using the Appropriateness Evaluation Protocol, a validated, clinically based utilization review instrument. METHODS: We assessed admissions by community-based and residency-based family physicians to a single university-affiliated hospital during calendar year 1988. A total of 905 patients were admitted to the hospital by family physicians during the study period. Of these, 889 records had complete data. Each was reviewed for appropriateness of admission. We calculated percentages of inappropriate admissions and used logistic regression to ascertain variables that were significant predictors of inappropriateness. RESULTS: Overall, 5.4 percent of admissions were categorized as inappropriate. Omitting obstetric cases, the rate was 10.5 percent. Inappropriate admissions did not cluster around a small number of diagnoses or diagnosis-related groups. Using logistic regression, we found that urgency of admission, patient insurance status, and residency-based physician admission versus community-based physician admission were significant predictors of inappropriate hospital use. Of the inappropriate admissions, 70 percent were so rated because diagnostic procedures or treatments could have been performed on an outpatient basis. CONCLUSIONS: In contrast with other studies for which physician specialty was not controlled, family physicians less frequently admitted patients inappropriately. Predictors of inappropriateness differed from those found in other studies. Changes in hospital systems, in addition to educational efforts directed toward individual physicians, hold promise as a strategy for reducing inappropriate hospital use.