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Biomedical subjects

S H Frank

Publications and source records attributed to S H Frank.

14 recordsLinked to original sources
PubMed2001

Addressing multiple problems in the family practice office visit.

OBJECTIVES: The purpose of the study was to describe the number of problems addressed during family practice outpatient visits, the nature of additional problems raised, how they affect the duration of the visit, and how well they are reflected in the billing record. STUDY DESIGN: Cross-sectional. POPULATION: We studied a total 266 randomly selected adult patient encounters representing 37 physicians. OUTCOMES MEASURED: A problem was defined as an issue requiring physician action in the form of a decision, diagnosis, treatment, or monitoring. Visit duration and the number of billing diagnoses were also assessed. RESULTS: On average, 2.7 problems and 8 physician actions were observed during an encounter. More than one problem was addressed during 73% of the encounters; 36% of these additional problems were raised by the physician and 58% by the patient. On average, each additional problem increased the length of the visit by 2.5 minutes (P<.001). The concordance between the number of problems observed and the number of problems on the billing sheet indicated a trend toward underbilling the number of problems addressed. CONCLUSIONS: Multiple problems are commonly addressed during family practice outpatient visits and are raised by both the physicians and the patients. Our findings suggest that current views of physician productivity and the billing record are poor indicators of the reality of providing primary care.

Adult↗
PubMed1997

Direct observation of community-based ambulatory encounters involving medical students.

CONTEXT: The current shift of predoctoral medical education from inpatient tertiary settings to community-based, ambulatory practice has raised questions about the effect of the medical student on the process of patient care. OBJECTIVE: To determine how the presence of a medical student during the ambulatory medical encounter affects the use of clinical time and patient satisfaction. DESIGN: Cross-sectional, multimethod study using direct observation of ambulatory care by research-trained nurses. SETTING: A total of 16 community-based family practice offices accepting family practice clerkship students. PATIENTS: A total of 452 outpatient visits with and without student involvement. MAIN OUTCOME MEASURES: Clinical time use as measured by the Davis Observation Code; patient satisfaction was assessed with the Medical Outcomes Study 9-item visit rating scale. RESULTS: When students were involved, physicians spent more time discussing visit expectations (P=.03) and less time in history taking (P=.007), providing assessment (P=.01), and answering questions (P=.04). Despite these differences, patients were equally satisfied with explanations received, and there was no change in the rank order of the 5 most commonly observed physician behaviors. There was no difference in time spent in treatment planning, physical examination, health education, or social chatting. The physician spent equal time with the patient with (10.3 minutes) and without (9.9 minutes, P=.6) student involvement. There was no decrease in patient satisfaction when students were involved. Physicians were more likely to discuss another family member's problems when a student was present (P=.001). Students were directed to care for minority patients at a disproportionate rate (P=.001), controlling for confounding variables. CONCLUSIONS: Medical student involvement alters the content but not the duration of the ambulatory medical encounter. Application of validated measures indicate that students did not impair patient satisfaction or hinder the physicians' ability to ensure that patient expectations for the visit were met.

Ambulatory Care↗
PubMed1993

Expectations disease: a model for understanding stress, control and dependent behaviour.

Most issues of emotional health seen in primary care do not fit standard psychiatric labelling. An integrative model is described for understanding the relationships between stress, control and dependent behaviours with clinical utility for primary care. In this model, expectations disease occurs when expectations consistently disable rather than enable. This clinical diagnosis is characterized by five disorders of control which contribute to recurring episodes of loss of control. Disorders of control include, 1) unmet or excessive need for control, 2) impaired recognition of controllability, 3) misattribution of control, 4) control dissimulation and 5) fear of loss of control. Definitions and behavioural consequences for each control disorder are described. Loss of control is defined as a cascade of behaviours invoked to avoid or diminish chaotic or dissonant thinking through actions one would not deliberately choose (or not choose to the same degree) while feeling in control. Examples of loss of control include substance abuse, anger (rage or violence), binge behaviours (eating, shopping, gambling, sex, overwork), depression, panic and somatization. Loss of control paradoxically results in a transient sense of relief or shift of focus from the problem stimulus, but inevitably creates further problems over time. Expectations disease is determined not by the presence or absence of control disorders, but by the degree to which these problems exist--their chronicity, intensity and rigidity. For some, this disorder may be acute or intermittent, for others chronic; for some, a nuisance, for other, disabling. Short-term intervention for patients who present with clear distress, but unclear diagnosis is discussed. Advantages and disadvantages of the model are detailed.

Behavior↗
PubMed1993

Area of Concentration programs in university-based family practice residency training.

To encourage pursuit of focused academic and clinical interest by family practice residents, we developed an Area of Concentration (AOC) program at a university-based residency program. The program uses resources available throughout the university and permits residents to focus on a variety of interest areas, including geriatrics, women's health, sports medicine, international health, behavioral medicine, and others. These AOCs are not fellowships but special longitudinal training experiences that occur throughout the duration of a standard residency program. Residents who have participated in our AOC program have become involved in research, published papers, and been invited to present their work at state and national meetings.

Curriculum↗
PubMed1993

Office evaluation and treatment of the dependent smoker.

Nicotine addiction is the most prevalent of all substance dependence, resulting in profound medical, social, and psychologic costs. Evidence supporting the addictive nature of nicotine is compelling. Recognition of this addiction has opened treatment options not currently available, including pharmacologic options. Physicians can contribute to cessation success even with minimal interventions. For those interested in stronger interventions, careful assessment of the smoker is essential. This assessment should identify the degree of nicotine dependence, the presence of negative affect related to cessation, and the pervasiveness of meaning of tobacco in the patient's life. Treatment options include white knuckle or will power quitting, guided self-treatment, referral, and office cessation with or without pharmacologic support. A four-visit protocol that includes (1) recruitment, (2) assessment, (3) treatment, and (4) relapse prevention is described.

Combined Modality Therapy↗
PubMed1992

Use of the Family CAGE in screening for alcohol problems in primary care.

OBJECTIVE: To establish the reliability and validity of the Family CAGE (an acronym indicating Cut down on drinking; Annoyed by complaints about drinking; Guilty about drinking; had an Eye-opener first thing in the morning), a four-item instrument intended to assess family alcohol-related problems. DESIGN: Two distinct cross-sectional studies using a survey, and in one study, retrospective chart review. PARTICIPANTS: A random sample of 172 adult patients presenting for nonurgent care to a network of family practice settings and a convenience sample of 107 patients who smoked presenting to a university family practice residency training setting. MAIN OUTCOME MEASURES: The Family CAGE was compared with alcohol-related variables and scales measuring psychosocial constructs. In the first study, these scales included the Family Stress and Coping Scale; Profile of Mood States; the Family Problems Checklist; and the Duke/University of North Carolina Mini-Health Profile. Chart review included medical utilization rates and prescription of medications. In the second study, a revised version of the Family CAGE was compared with other scales such as the standard CAGE questionnaire; an "Anomy" Scale; the Catchment Epidemiologic Study-Depression Scale; a global self-assessment of alcohol-related problems; and a self-report of lifetime history of major depression and recent self-limited depression. RESULTS: The Family CAGE showed strong internal consistency reliability, with Cronbach's alpha coefficients of .84 in the first study and .89 in the second. Construct validity was supported by Family CAGE correlations with family stress, family problems, depression, anxiety, individual stress, and marital dissatisfaction. The Family CAGE was strongly correlated with global assessment of family alcohol-related problems, and was superior to this variable in predicting help-seeking behavior. The Family CAGE was also significantly correlated with a higher sick visit rate and more medications prescribed (despite no difference in functional health status). The standard CAGE was correlated with a recent history of self-limited depression, while the Family CAGE was correlated with a lifetime history of major depression. Sensitivity and specificity rates vary depending on the criterion addressed, but a cutoff score of 2 or more appears to offer the best clinical information. CONCLUSION: The Family CAGE appears to be a reliable, valid, utilitarian measure of family alcohol problems. It offers more information than either a single-item global assessment regarding family alcohol-related problems or the standard CAGE questionnaire. The Family CAGE is strongly correlated with other important psychosocial problems, prescription of psychotropic medications, and health-care utilization. It is brief, understandable, and equally effective in interview and self-administered formats.

Adult↗
PubMed1992

The focused physical examination. Should checkups be tailor-made?

The "complete physical examination" taught in medical schools is not always the best approach to clinical assessment of asymptomatic adults. The authors of this article review the controversy surrounding the utility of routine physical examination, advocating evolution in medical practice from use of the complete physical examination toward the focused physical examination.

Aged↗
PubMed1992

A clinical trial to reduce the rate of low birth weight in an inner-city black population.

BACKGROUND: The goal of our study was to measure the effectiveness of a home-based intervention for prevention of low birth weight with 154 high-risk, low-income black women attending a prenatal clinic in Cleveland. METHODS: Based on previous research, risk was defined by clinic registration between the 17th and 28th weeks of gestation, low family functioning score, and experience of at least one stressful life event prior to registration. Optional factors included being a smoker, a low maternal weight-height ratio, being age 27 or older, and a previous premature birth. A 21-item family function screen previously validated in a similar population was the primary determinant of psychosocial risk. Low birth weight was defined as weight less than 2,500 g regardless of gestational age. RESULTS: There was no decrease in the rate of low birth weight for women who received four home visits focusing on smoking, drug and nutrition education, support, and links with community services, compared to women who received no visits. The number of prenatal visits was significantly higher in the intervention group, but an increased number of prenatal visits did not correlate with a reduced rate of low birth weight. Despite previous research, the family function screen was not an effective predictor of low birth weight in our study. A revised equation involving a history of previous premature birth, smoking, and a low maternal weight-height ratio did predict low birth weight. CONCLUSIONS: These findings question the utility of short-term psychosocial interventions for influencing low birth-weight rates in low-income black clinic populations. The family function screen was not cross validated. Integration of any psychosocial intervention with the routine prenatal care occurring in the obstetrical clinic is suggested for future research.

Adolescent↗
PubMed1991

A critical review of labor and birth care. Obstetrical Interest Group of the North American Primary Care Research Group.

A critical review of the literature regarding important aspects of labor and delivery was conducted by members of the Obstetrical Interest Group of the North American Primary Care Research Group using computerized searches, personal communication, and literature exchange between group members. Each written topic summary was carefully reviewed by a second group member, and a consensus was reached regarding conclusions and recommendations by the group. The topics include family involvement, comfort measures, fetal heart rate monitoring, labor augmentation, birth positions, and episiotomies. Each topic summary is preceded by conclusions and recommendations given in the order of least invasive to most invasive of the woman in labor. The strength of these conclusions and recommendations is based on the amount and type of supportive data in the literature and is indicated by one to three stars preceding that statement. One-star conclusions are not well supported in the literature but reflect a family practice style and were reached through consensus from the group. Three-star conclusions are supported by data from clinical trials.

Delivery, Obstetric↗
PubMed1989

Urolithiasis in primary care.

Urolithiasis is a common, multifactorial, medically manageable disease. Primary care physicians can play a prominent role in metabolic evaluation and medical treatment of patients with urolithiasis. Patients should be referred for urologic evaluation in the presence of intractable urinary tract infection, progressive renal damage, urinary obstruction, refractory pain, or presence of stones of uncertain etiology. Expectant management of symptomatic ureteral stones can be undertaken by a primary care physician in conjunction with urologic support. Interventional treatment of urinary stones has improved markedly with the availability of extracorporeal shock-wave lithotripsy, and percutaneous stone removal. In patients with certain types of urinary stones, medical treatment can greatly reduce the incidence of subsequent stone-forming episodes.

Diagnosis, Differential↗
PubMed1988

Stress in the clinical setting: the Brief Encounter Psychosocial Instrument.

Integration of knowledge regarding the relationship between stress and illness into clinical practice has been slowed by a lack of clarity in the definition of stress and the difficulties involved in rapid assessment of stress in a busy office setting. The stimulus, response, and interactional models of stress are discussed, and the development of a new stress measure, the Brief Encounter Psychosocial Instrument (BEPSI), is detailed. The reliability of this six-item instrument is demonstrated (Cronbach's alpha .80). Validity is measured through correlation with a variety of instruments measuring stress, including depression (r = .52, P less than .001), anxiety (r = .61, P less than .001), life change (r = .56, P less than .001), bodily expression of stress (r = .56, P less than .001), and a total stress score (r = .67, P less than .001). The BEPSI also demonstrated appropriate negative correlations with family cohesion (r = .29, P = less than .01) and support (r = .31, P = less than .01). When the single open-ended item is strongly positive, 77 percent of patients also score high on the BEPSI. A negative response to the same question corresponds to a low BEPSI value 52 percent of the time. Suggestions are made regarding clinical and research applications.

Adolescent↗