* BACKGROUND Ineffective management of laboratory test results can result in suboptimal care and malpractice liability. However, there is little information available on how to do this important task properly in primary care settings.

* METHODS We used a questionnaire guided by a literature review to identify a conceptual model, current practices, and clinicians who reported having an effective method for at least one of 4 steps in the process of managing laboratory test results. Clinicians with differing methods were selected for each of the steps. Practice audits and patient surveys were used to determine actual performance. On the basis of these audits, we constructed a unified best method and conducted time-motion studies to determine its cost.

* RESULTS After auditing only 4 practices we were able to identify effective methods for 3 of the 4 steps involved in the management of laboratory test results. The unified best method costs approximately $5.19 per set of tests for an individual patient.

* CONCLUSIONS By identifying effective practices within a family practice research network, an effective method was identified for 3 of the 4 steps involved in the management of laboratory test results in primary care settings.

* KEY WORDS Laboratories; primary health care; communication; practice management, medical.
Failure to notify patients of abnormal laboratory test results or to ensure appropriate follow-up can result in inferior patient care and potential malpractice liability.[1-5] Failure to document physician review and communication of test results to patients can make defense of a malpractice claim more difficult. Our review of the English-language literature identified only a few studies related to the management and reporting of laboratory test results in primary care.

In two U.S. studies about medical errors in 2000 and 2001, family physicians offered their ideas on how to prevent, avoid, or remedy the five most often reported medical errors. Almost all reports (94 percent) included at least one idea on how to overcome the reported error. These ideas ranged from “do not make errors” (34 percent of all solutions offered to these five error types) to more thoughtfully proposed solutions relating to improved communication mechanisms (30 percent) and ways to provide care differently (26 percent). More education (7 percent) and more resources such as time (2 percent) were other prevention ideas.

Of 416 error reports made by U.S. family physicians in two medical error studies in 2000 and 2001, 151 (36 percent) were about the most commonly reported errors involving the processes of ordering medications, implementing laboratory investigations, filing forms and maintaining patient records, implementing medication orders, and responding to abnormal laboratory test results.

Although identifying medical errors is an important first step in making primary care safer for patients, the major challenge is in finding ways to avoid them. When asked for their ideas on how to overcome the most common medical errors they reported, family physicians offered 228 distinct solutions, categorized in the accompanying table.

In 2000 and 2001, before patient safety was widely discussed in primary care settings, one third of family physicians’ solutions for overcoming medical error were not very helpful–doing the same thing, but better. The practicing environment may make it difficult for physicians to think in terms of systems or to imagine alternatives to their immediate realities. Surprisingly, only a small minority of the other, more practical solutions for overcoming medical errors in primary care required additional resources, and these resources were almost always time-related rather than monetary. Specific changes such as stopping the use of carbon copy prescription forms, doing urgent laboratory tests in the office, and using flagging systems to draw attention to information needing action were all practical suggestions for alleviating these common errors. Various double-checking systems also were favored. In searching for solutions to medical errors, asking those involved in providing care for their ideas may be a rewarding strategy.

Medical and technological advances in abortion care, including the introduction of mifepristone and the refinement of uterine aspiration techniques, have enabled earlier and simpler termination of unwanted pregnancy. These technologies are well suited for use by a wide range of health care providers in various settings. Expanding the number of providers offering early abortion care is particularly important in rural and underserved areas in the United States, where the number of abortion providers has been declining dramatically. From 1996 to 2000, the number of recognized abortion providers in California decreased by 19%; currently only 400 providers serve 7.5 million women of reproductive age in the state. (1)

In the United States, nonphysician clinicians, including advanced practice clinicians, are playing increasingly important roles as providers of health care. From 1987 to 1997, the proportion of patients who saw a nonphysician clinician increased from 31% to 36%. (2) Advanced practice clinicians-including nurse practitioners, physician assistants and certified nurse-midwives–have been shown to competently perform complex medical procedures and provide high-quality care. (3) Several advocacy and professional organizations have recognized advanced practice clinicians as technically qualified and appropriate providers of abortion care. (4) During their clinical training, advanced practice clinicians specializing in women’s health learn several related and equally complex skills, including how to date pregnancies by measuring uterine size and using ultrasonography, insert IUDs, perform intrauterine biopsies, suture simple lacerations and repair episiotomies. Although some states have laws that limit abortion care to physicians, advanced practice clinicians may assist physicians by providing counseling, taking medical histories, performing physical examinations (including to confirm and date a pregnancy) and managing side effects.

Edward Langston, M.D., Lafayette, Ind., was recently elected to a seat on the American Medical Association (AMA) Board of Trustees. Dr. Langston, who was nominated by the AAFP, is a past chair of the AMA Specialty and Service Society and has been a member of the AMA Council on Medical Education since 1997. He served on the AAFP Board of Directors from 1991 to 1993 and was Board vice president in 1994. AAFP member J. Edward Hill, M.D., Tupelo, Miss., was re-elected to the AMA Board of Trustees. Dr. Hill has been a member of the AMA board since 1996 and is the immediate past chair. Family physician Ann Jobe, M.D., M.S.N., Macon, Ga., was named chair-elect of the AMA Section on Medical Schools, and David Barbe, M.D., a family physician in Mountain Grove, Mo., was chosen to serve on the AMA Council on Medical Service.

A Report from the Ambulatory Sentinel Practice Network

* BACKGROUND Care of a secondary patient (an individual other than the primary patient for an outpatient visit) is common in family practice, but the content of care of this type of patient has not been described.

* METHODS In a cross-sectional study, 170 volunteer primary care clinicians in 50 practices in the Ambulatory Sentinel Practice Network reported all occurrences of care of a secondary patient during 1 week of practice. These clinicians reported the characteristics of the primary patient and the secondary patient and the content of care provided to the secondary patient. Content of care was placed in 6 categories (advice, providing a prescription, assessment or explanation of symptoms, follow-up of a previous episode of care, making or authorizing a referral, and general discussion of a health condition).

* RESULTS Physicians reported providing care to secondary patients during 6% of their office visits. This care involved more than one category of service for the majority of visits involving care of a secondary patient. Advice was provided during more than half the visits. A prescription, assessment or explanation of symptoms, or a general discussion of condition were provided during approximately 30% of the secondary care visits. Secondary care was judged to have substituted for a separate visit 60% of the time, added an average of 5 minutes to the visit, and yielded no reimbursement for 95% of visits.

* CONCLUSIONS Care of a secondary patient reflects the provision of potentially intensive and complex services that require additional time and are largely not reimbursed or recognized by current measures of primary care. This provision of secondary care may facilitate access to care and represent an added value provided by family physicians.

Dr. Andrewes said: My first and most pleasant duty is to bid a hearty welcome to the newcomers to this school, and I trust that you will gain here not only adequate u’aining in the profession you have chosen which this school is now more than ever fitted to give you, but also a number of firm friendships and pleasant memories which will remain for your whole lives. I have next to say something to you–not new, indeed, but I hope true–about the methods of medical education, and especially about the value of a rational perspective in your studies. The enthusiasm for work, which I have found even keener amongst women students than amongst men, entails the risk that you may spend time over things that matter little, leaving insufficient space fbr more vital matters. It should be the main function of your teachers to direct your energies into the most important channels. No one can in five, or even in fifty, years learn all that one could wish about disease and its prevention and treatment. You have to go on learning all your lives, and, a healthy sense of ignorance is a saving grace. But there are three things which you must learn in your five years of medical study. You have to learn how to learn. Then you have to learn as much as you can of those things which are of immediate and cardinal importance, and which will serve as the groundwork for furore learning after you commence practice. Lastly, you have to learn how to set forth what you have learned in such a manner as to persuade a Board of Examiners that you are fit and proper persons to be let loose on the public as qualified medical practitioners.

On July 31 the Medscape Web site, named the official provider of online coverage for the new International AIDS Society conference which took place July 8-11, 2001 in Buenos Aires, Argentina, released three Continuing Medical Education programs for medical professionals. Anyone can use them for a review of current knowledge in some of the major areas of HIV treatment. These programs will remain online for one year.

The Medscape site requires a one-time registration, but it is cost-free.

Here we list the titles of the programs and the articles required for CME credit in each one. Each program also has several other articles available which are not listed here.

I. Current Patient Management:

* New Light Through Old Windows: Fine-tuning the Use of Approved Antiretrovirals, by Graeme Moyle, M.D., M.B.B.S.

* Pharmacokinetics, Pharmacodynamics, and Pharmacogenomics: The Continuing Evolution of Pharmacologic Issues in HIV Disease, by Stephen Becker, M.D.

* Update on Antiretroviral Drug Resistance, by Daniel R. Kuritzkes, M.D.

* Management of HIV-Infected Women and Mother-to-Child HIV Transmission, by Alexandra M. Levine, M.D.

II. Novel Therapeutic Strategies

* HIV Entry — From Molecular Insights to Specific Inhibitors, by William A. O’Brien, M.D., M.S.

* Investigational Antiretrovirals in Existing Classes, Mike Youle, M.B.B.S.

* Strategies for Immune Reconstitution in HIV Disease, by Ronald T. Mitsuyasu, M.D.

* Insights From Basic Science: Implications for HIV Treatment and Prevention, Mark A. Wainberg, Ph.D.

III. Complications of HIV Disease

* Opportunistic Infections: Still a WorldWide Problem, Even in the HAART Era, by Henry Masur, M.D.

* New Developments in AIDS-Related Hematology and Oncology, by Alexandra M. Levine, M.D.

* Adverse Effects of Antiretroviral Therapy: More Noise, Less Clarity?, by William G. Powderly, M.D.

The Council on Graduate Medical Education (COGME) recently elected F. Marian Bishop, Ph.D., M.S.P.H., as its new vice-chair. Bishop is currently professor and chair emeritus of the University of Utah School of Medicine’s Department of Family and Preventive Medicine, Salt Lake City. The COGME advises the Department of Health and Human Services (HHS) Secretary and Congress on physician workforce trends, training issues and financing policies. The council also makes recommendations about the supply and distribution of physicians and the appropriate efforts of hospitals, medical schools, and accrediting bodies to deliver health care to the nation. Bishop has been president of the STFM and the Association of Teachers of Preventive Medicine, and has served on the National Health Service Corps Advisory Council and the Executive Committee of the National Board of Medical Examiners.

Case Study

TC is a 24-year-old woman who comes to your office for a well-woman visit. Her last physical examination was at age 16 with her pediatrician. She has been sexually active since the age of 15 and has had three “lifetime” partners. TC has been monogamous with her current partner since they were married four months ago. She is currently taking oral contraceptive pills and has used condoms inconsistently in the past. TC has had two miscarriages and also has a family history of breast cancer. She has never been tested for sexually transmitted infections and asks if this is necessary.

The case study and answers to the following questions on screening for chlamydia are based on the recommendations of the current U.S. Preventive Services Task Force (USPSTF), part of the Put Prevention into Practice program of the Agency for Healthcare Research and Quality (AHRQ). This recommendation was released in 2001 and is an update of the 1995 USPSTF Recommendations and Rationale Statement on screening for chlamydial infection. More detailed information on this subject is available in the Systematic Evidence Review, Summary of the Evidence, and USPSTF Recommendations and Rationale on the AHRQ ; through the National Guideline Clearinghouse ;and in print through the AHRQ Publications Clearinghouse (800-358-9295) and the April 2001 Supplement to the American Journal of Preventive Medicine.

Because FIPSE is so well known for its support of innovation and reform in numerous other areas, few outside of the education field have appreciated the centrality of its role in sponsoring innovations in the medical and health sciences. These changes have been varied and far reaching, and they have addressed some of the basic concerns about the provision of health services and medical training in this country. Some were motivated by notions that health service providers can be poor communicators or lack empathy. Others focused on the problem of assessing clinical competencies, exacerbated by concerns of the patients upon whom students practiced their new skills. Still others arose from the perception that the specific health needs of some groups were not receiving enough attention.

The demand to better prepare health-care providers in these and other areas collided with a curriculum that has exploded with so much content that it is often unmanageable–even while many are urging the addition of new content and altered pedagogy to provide more relevant learning and to motivate students to become more active participants in the learning process. And all of these demands come at a time when diminished funding within the health sciences has made innovation difficult.

FIPSE’ s role in supporting change has therefore been vital. But why FIPSE? Because no one else offers significant funding for research and innovation in medical and health education. The National Institutes of Health (NIH) has had and continues to have an essential and respected role in funding fundamental and clinical research in medicine and health, but support of education has not been part of its mandate. From its founding onward, the National Science Foundation (NSF) has supported science education, including pre-medical education, but as a matter of policy excludes the applied clinical sciences from all of its funding programs. So there is no agency other than FIPSE whose primary mission includes support for change in medical and health education.