Results released by the National Resident Matching Program (NRMP) indicates that the 2002 national fill rate for family practice residency positions was 79 percent (2,357 positions filled of 2,983 position offered), representing an increase from last year’s 76.3 percent. The fill-rate percentage for seniors in the United States fell from 49 percent in 2001 to 47.4 percent in 2002.

The conclusion of the 2002 match was that medical students are continuing to demonstrate a slight preference for medical subspecialties over primary care practice and are selecting careers that provide more flexible lifestyle choices, potential for greater financial incentives, fewer external productivity pressures, and more generous third party-payer reimbursement.

A study at the Manitoba Health Centre suggests that it will not. According to a study reported in the Journal of the Canadian Medical Association in August:

* Family practicioners between 30 and 49 years of age (64% of the workforce) provided 20% fewer visits per year than their same-age peers did 10 years previously.

* Conversely, FPS 60 to 69 years of age (11% of the workforce) provided 33% more visits per year than the corresponding group a decade earlier.

On a per capita basis, the number of FPS declined by 5%, from 97 per 100,000 population in 1991/92 to 92 per 100 000 population in 2000/01, which paralleled changes in national estimates of FP supply.

Per capita visit rates among Winnipeg citizens (3.5 per year in 2000/01) and average work-loads among FPS (4,193 visits per year in 2000/01) were stable over the decade.

“Given these data, the perpetual focus of policy-makers and care providers on increasing numbers of FPS will not help in diagnosing or treating issues of supply, workloads and access to care,” the article states.

A call for papers has been issued by the American Academy of Family Physicians (AAFP) for possible presentation at the 2000 Scientific Assembly to be held September 20-24 in Dallas. Applications must be submitted by April 3, 2000. Membership in the AAFP is not a prerequisite for submission.

Applications may be submitted in two different categories. Category I is for original research relevant to family practice; category II includes case studies and literature reviews. Each category has six author classifications: family physicians and fellows primarily in academic medicine, family physicians primarily in clinical practice, family practice residents, medical students, international attendees and others. The international attendee classification is open to anyone outside the United States who conducted clinical or educational research relevant to family medicine.

The winning presentations in each category will receive cash awards of $1,000. Runners-up will receive $250. All awards are given at the discretion of the Subcommittee on Family Practice Research Presentations. Application forms may be obtained from Carrie Vickers, Scientific Assembly Department, AAFP, 11400 Tomahawk Creek Pkwy., Leawood, KS 66211; telephone: 800-274-2237, ext. 6568.

In 2004, the National Guidelines Clearinghouse placed eight guidelines from the National Health Care for the Homeless Council on its Web site. Seven of the guidelines are on specific disease processes and one is on general care. In addition to straightforward clinical decision making, the guidelines contain medical information specific to patients who are homeless. These guidelines have been endorsed by dozens of physicians who spend a large part of their clinical time caring for some of the millions of adults and children who find themselves homeless each year in the United States. In one guideline, physicians are prompted to keep in mind that someone living on the street does not always have access to water for taking medication. Another guideline points out the difficulty of eating a special diet when the patient depends on what the local shelter serves. As the number of homeless families and individuals increases, family physicians need to become aware of medically related information specific to this population. This can help ensure that physicians continue to offer patient-centered care with minimal adherence barriers.

Each day in the United States, at least 800,000 persons are homeless. This includes 200,000 children in homeless families. (1) As of the beginning of the 21st century, 2.3 to 3.5 million persons were homeless at some time during an average year. (2) Approximately 33 percent of these are families with children, and another 3 percent are unaccompanied minors. (3) Two percent of children in the United States are homeless in the course of a year. (4) Figure 1 (3) shows the composition of the homeless population in the United States.

The Federal Bureau of Primary Health Care defines homelessness using the following descriptors (5):

* An individual without permanent housing who may live on the streets; stay in a shelter, mission, single-room occupancy facility, abandoned building or vehicle; or in any other unstable or nonpermanent situation.

* An individual may be considered homeless if that person is “doubled-up”, a term referring to a situation in which individuals are unable to maintain their housing situation and are forced to stay with a series of friends or extended family members.

* Previously homeless individuals who are to be released from prison or a hospital may be considered homeless if they do not have a stable housing situation to return to.

* Recognition of the instability of an individual’s living arrangement is critical to the definition of homelessness.

State, city, or private definitions (e.g., ones used for grants or to receive certain subsidies) may differ from this.

At the beginning of this century, clinicians from the National Health Care for the Homeless Council (NHCHC) began to adapt clinical practice guidelines for patients who are homeless. In 2004, the National Guidelines Clearinghouse placed eight NHCHC guidelines on its Web site, including seven relating to specific disease processes and one on general care (online Table A). Well-researched evidence that differentiates care for the homeless population from the general population is almost nonexistent. Therefore, the method used to assess the quality and strength of the evidence for those criteria and to formulate recommendations was based almost entirely on expert consensus.

This article summarizes some of the NHCHC guidelines that apply to a variety of conditions that pertain to persons who are homeless. Although some of this information is duplicated in other NHCHC guidelines, most of it comes from the NHCHC’s general recommendations, 6 except when noted otherwise. In addition, some relevant information from more recent literature on the topic is included.

Overcoming Barriers to Care

Millions of persons in the United States with minimal health care access experience barriers to care, but persons who are homeless face additional unique obstacles. Difficulties can arise when a physician tries to build trusting relationships in a population where histories of mental illness and abuse are often the norm. Even when trust is won, finding the appropriate prescribing patterns and education techniques to help ensure adherence can be a challenge for any physician, particularly when food and housing concerns often outweigh those for ongoing health care. Ideally, physicians should develop individualized care plans that incorporate the meeting of basic daily needs.

Unrealistic expectations by physicians are a key cause of patient nonadherence. (5) When adherence is a problem, the physician should reassess goals with the patient. Knowing some of the issues that affect adherence for persons who are homeless may help clarify any unrealistic expectations (Tables 1 and 2 (6-10)).

Building Trust

A full-body, unclothed, comprehensive examination of an adult who is homeless is rarely possible before patient-physician trust and engagement is achieved. Approximately 25 percent of these patients have at some time experienced severe mental disorders such as schizophrenia, major depression, or bipolar disorder, and many are survivors of physical or sexual abuse and/or assault. (11-14) In addition, many have experienced negative interactions with authority figures, and because anxiety is highly prevalent in the homeless population, these patients may be averse to the private aspects of the physical examination.

The FDA approved the ThinPrep[R] Pap Test[TM], a liquid-based cervical cancer screening test, in 1996 (Johannes 1998) (Cytyc Corporation 2001). Ever since, the ThinPrep Pap test has been rapidly replacing the conventional Pap smear, even though it is about twice as costly as conventional Pap smears (Johannes 1998; Rubin 2002). According to the manufacturer, the Cytyc Corporation of Boxborough, Massachusetts, the test is now used in lieu of a conventional Pap smear in the United States for approximately two-thirds of cervical cancer screenings, a proportion that keeps increasing (Rubin 2002).

Although liquid tests are more effective at detecting precancerous changes and are associated with fewer numbers of ambiguous diagnoses than conventional Pap smears, most of the improvement in test accuracy is in the detection of low-grade lesions that often regress spontaneously (Brown and Garber 1999). Liquid-based technologies have not been shown to be superior to conventional Pap smears at detecting frank cancer and have not been associated with lower mortality from cervical cancer compared with Pap smears. Screening with conventional Pap smears once every three years between the ages of 20 and 75 increases the average woman’s life expectancy by about 96 days (Eddy 1990). According to Brown and Garber (1999), annual screening with the ThinPrep Pap test would prolong the average woman’s life approximately an additional six hours over annual screening with conventional Pap smears. In triennial screening programs, use of the ThinPrep Pap test instead of conventional smears would prolong the average woman’s life about 19 hours (Brown and Garber 1999).

The lower rate of false positive cervical cancer screening tests is one reason for the rapid diffusion of the liquid-based tests, but other factors may also explain their rapid emergence in medical practice. The Cytyc Corporation, the makers of the ThinPrep[R] Pap Test[TM] test (the most commonly used liquid test), actively marketed it to physicians and the general public. The company also encouraged insurance companies to promote themselves to women by including information about their coverage of ThinPrep in advertising campaigns (Johannes 1998).

Articles concerning how physicians learn about new pharmaceutical agents began to appear in the medical literature in the 1950s (Peay and Peay 1994). In recent years, articles have focused on the influences of marketing to physicians on prescription behavior (Avorn, Chen, and Hartley 1982; Manning and Demon 1980) as well as the effect of marketing prescription drugs to the public (Bell, Kravitz, and Wilkes 1999; Wilkes, Bell, and Kravitz 2000; Avorn and Solomon 2000). However, little attention has been given to marketing of laboratory tests used in office-based practice. There is scant information on how office-based physicians choose new diagnostic tests. This paper examines adoption of liquid-based cervical cancer screening tests among family physicians and gynecologists in Maryland. We hypothesized that the efforts of Cytyc Corporation to market the ThinPrep Pap test would be an important determinant of its early adoption by physicians. Additionally, we examined the effects of physician specialty, patient sociodemographics, practice factors, and financial constraints on laboratory decision making on the adoption of liquid-based cervical cancer screening tests.

METHODS

Study Population

The American Medical Association Master File of Physicians was used to create a sampling frame of Maryland family physicians and gynecologists. The selection criteria resulted in a total of 2,025 physicians (1,079 family physicians and 946 gynecologists). Physicians who did not graduate from medical school between 1950 and 1989 were excluded in an effort to restrict the sample to physicians still in practice who had had experience with conventional Pap smears before liquid-based tests were available. Physicians known to be working in federal facilities were also excluded. We randomly selected 250 physicians from each of the two specialty groups using a random number generator. Assuming a 50 percent response rate, this sample size would detect a difference of at least 20 percent in the adoption rates for these groups with a power of .85 (two-tailed alpha of 0.05).

Between July and October 2000, the name of each physician was searched on the web site of the American Medical Association (American Medical Association 2001) and the Yahoo search engine on the Internet for a current Maryland address and telephone number (Yahoo yellow pages 2001).

The medical offices of the physicians were then contacted by telephone to determine if the physician offered routine gynecologic care with screening for cervical cancer. The office staffs of physicians chosen for the study were asked to verify addresses and provide fax numbers. In order to obtain basic information about all physicians in the study, including those who did not eventually respond to the questionnaire, the office staffs were also asked if the physicians use a liquid-based cervical cancer screening test, either the ThinPrep Pap test or AutoCyte (a less commonly used test), conventional Pap smears, or both.

According to research in the December issue of Academic Medicine, rules implemented in 2003 restricting the number of hours medical residents can work have had an impact on family medicine residency programs. Residency program directors reported an increase in faculty patient care duties, a decrease in formal resident educational activities, a decrease in specialty clinic rotations for residents, and a decrease in residents caring for their patients in continuity clinics.

Many practicing physicians, national organizations of health care professionals, medical educators, government agencies and the public support the belief that preventive care services should be delivered by physicians. Unfortunately, most studies indicate that compliance wih recommended preventive care guidelines is low. In most intervention studies designed to increase implementation of health maintenance, the performance of screening tests, counseling and immunizations rises to only about 50 percent in eligible patients. Hahn and Berger evaluated the use of a systematic health maintenance protocol in over 1,400 patients seen in a family practice setting over an 18-month period. The results obtained with the protocol were compared with the results of “usual care.”

At the end of each patient visit, an adult health maintenance flow sheet was reviewed with the patient to determine if indicated procedures had been performed and, if so, whether the results were normal. The physician recommended procedures that had not been performed and provided a brief explanation of each. The flow sheet consisted of ten to 15 health maintenance items, including a Papanicolaou test, blood pressure reading and tetanus booster. The protocol took between two and four minutes to complete.

After 18 months, a random audit of medical records showed that physician compliance with the protocol was 97 percent in eligible patients. Patient acceptance of recommended preventive services varied from 77 percent (sigmoidoscopy) to 97 percent (cholesterol screening). The patients in the usual care group received significantly fewer preventive services.

The following guidelines have been developed and endorsed by the American Academy of Family Physicians.

Approved by the AAFP Board of Directors in November 1993, these guidelines represent the “core” educational objectives for training family practice residents in the field of risk management and medical liability. Family physicians in practice may wish to review the guidelines in preparing for their board examinations. Other specialists may refer to the guidelines in developing continuing education courses for family physicians or in preparing articles for American Family Physician.

Risk management refers to strategies that reduce the possibility of a specific loss. The systematic gathering and utilization of data are essential to this concept. The risk management process comprises:

* Identification of risk or potential

risk (diagnosis)

* Calculation of the probability

of adverse effect from the risk

situation (assessment)

* Estimation of the impact of the

adverse effect (prognosis)

* Control of the risk (management)

Good risk management techniques improve the quality of patient care and reduce the probability of an adverse medical malpractice claim.

This core curriculum outlines the attitudes, knowledge and skills currently recommended for residents in the area of risk management.

Attitudes

The resident should develop attitudes based on:

A. An awareness of potential risk

and professional liability.

B. An appreciation of the importance

of good communication.

C. An appreciation of the importance

of good medical records.

D. A sensitivity to the roles of federal,

state, commercial and

other agencies involved in risk

management and medical

liability issues.

E. An awareness of the inherent

conflict between defensive

medicine and cost

effectiveness, between individual

good and social good.

Knowledge

A. Physician-patient relationship

1. Definition

2. Termination

a. Mutual consent of parties
b. Physician services no
longer needed
c. Withdrawal of physician
from case after
reasonable notice to
patient and completion of
current treatment

3. Abandonment

B. Informed consent

1. Components

a. Diagnosis
b. Nature and purpose of
proposed treatment
c. Possible complications
d. Available probability of
success
e. Alternatives
f. Documentation of
conversations
g. Written form completed

2. Special patient situations

a. Minors
b. Mental incompetence
c. Emergencies
d. Therapeutic privilege

C. Communication

1. Doctor/patient

a. Time spent with patients
b. Use of clear, understandable
language
c. Careful and attentive listening
d. Sensitivity to needs of
patients
e. Flexibility in responses
to the spectrum of
patients
f. Mechanism for
addressing patient
complaints

2. Staff communication with

patients

3. Doctor/legal system

a. Response to request for
records
b. Subpoenas
c. Depositions
d. Attorney selection
e. Malpractice panels
f. Court appearances

D. Legal definitions

1. Sources of the law

a. Supreme law
b. Statutory law
c. Decisional law
d. Quasi-judicial law

2. General legal liability

a. Contract
b. Torts, intentional
negligence

3. Duty to exercise care

4. Applicable standard of care

5. Breach of standard of care

6. Causal relationship between

breach of duty and injury

7. Statute of limitations

8. Statutory immunity

E. Documentation

1. Physician record

a. Accurate
b. Complete
(1) Patient
examination
(a) Baseline history
and physical
examination
(b) Updated lists of
known allergies,
prior illnesses,
immunization
status
(c) Specific notes on
symptoms, patient
noncompliance,
patient responses
(2) Patient disposition
(a) Differential diagnosis,
current
diagnosis, therapy,
plan of action
(b) Specific time of
return visit
(c) Referral to other
physicians
including reasons
and date of
appointment
(d) Follow-up system
(3) Telephone calls
(a) Substance of telephone
conversation,
both during
and after office
hours
(b) Conversations
with patient, family
members and
other physicians
(4) Reports of tests
(a) Physician
acknowledgment
of results
(b) Inclusion in chart
(c) Follow-up plan for
abnormal results
(5) Technical matters of
form
(a) Preprinted forms
with fill-in-the-blank
style
(b) Little empty paper
(white space)
(c) All entries signed
and dated
(d) Pages securely
bound
(e) Complete entry
at time of
examination
(f) Missed or canceled
appointments noted
(g) Problem list
c. Legibility and readability
d. Proper corrections and
modifications
e. Timely completion of
medical records
f. Confidentiality
(1) Legal breach of
confidentiality
(a) Physical or sexual
abuse of children
(b) Patient presents
clear danger to self
or others
(c) Patient to be
involuntarily committed
to mental
health facility
(d) Certain health
conditions, i.e.,
human immunodeficiency
virus
(e) Reportable
communicable
diseases, i.e.,
tuberculosis, sexually
transmitted
diseases

The new Institute of Medicine definition of primary care is not vet operational since it is unknown whether its description fits reality. Different primary care clinicians, ie, family physicians, pediatricians, general internists, and nurse practitioners, have different frames of reference, training programs, and views on their involvement in the delivery, of care.Rapid changes in the United States health care system complicate the operationalization of the definition considerably, especially with regard to the central issue of the large majority of personal health care needs.

The episode of care is designated as the unit of assessment for deciding whether a clinician indeed provides care for the large majority of health care needs of persons who consider him or her their usual provider. The term episode of care refers to a health problem from its first encounter with a health care provider through the completion of the last encounter related to that problem.  An episode of care, therefore, differs from an episode of disease, which is a health problem from its onset through its resolution or until the patient’s death, and an episode of illness, which is the period during which a person suffers from symptoms or complaints experienced as an illness. Not every disease and certainly not every illness results in an episode of care. Most episodes of care, however, are part of an episode of disease and, less often, of illness. Health maintenance episodes can be considered a special form of episodes of care.

The prevalence of an episode of care consequently is lower than the prevalence of a given disease in the population. For some diseases, the prevalences will be similar, as with fractures, strokes, metastatic malignancy, and blindness. More often, however, there will be considerable discrepancies between the actual demand for care and the potential need as expressed by data from population studies (disease), from health interviews (illness + disease), and from utilization studies (care). In the United States, the National Ambulatory Medical Care Survey,[10] National Health Interview Survey, and National Medical Expenditure Survey are major sources for such data.

A Core Concept for Family Practice

The episode of care is central to the use of the International Classification of Primary Care (ICPC), developed by the World Organization of Family Doctors. This system is designed to characterize the three essential elements of primary care episodes: the patient’s reason for the encounter, the diagnostic label, and the diagnostic and therapeutic intervention.

The content of primary care has been described in several epidemiologic studies. From these studies, the family doctor emerges as the prime candidate to meet the requirement of dealing with the large majority of personal health care needs. Everyone for whom a family physician is the usual provider of care can present to him or her with any health problem at any stage of development. These problems as distributed represent the large majority of personal health care needs for different sex and age groups and are globally known, in both the United States and elsewhere.

In addition to providing personal continuity of care, family physicians also provide factual continuity of care when they structure and update the medical life histories of their patients over time, taking into account the changes in medicine, in society and in their patients’ lives.

The main goal of this article is to illustrate how the content of family practice can be characterized in an episode-oriented epidemiologic model,

Methods

In the Netherlands, patients cannot seek specialist care without a referral by the family physician. This circumstance allows a rather close approximation of the large majority of personal health care needs. The Dutch health care system, in which family physicians are designated as primary care physicians, differs from that in the United States, where not only family physicians but also general internists, pediatricians, and gynecologists serve as primary care clinicians.

Data on patients enrolled (listed) with a family physician are presented in the form of standard presentations with a 1-year time window (Transition project of the Department of Family Practice, University of Amsterdam). In the period 1985 to 1994, complete data on 236,023 episodes of care during 93,297 patient years were routinely registered and coded by 43 family physicians. Data on episodes of care in women 2 5 to 44 years of age have been selected for use in this paper to provide an indication of the potential involvement of different primary care providers, ic, family physicians, general internists, and gynecologists, in the large majority of the health care needs in this group.

Few of us today realize that only a quarter of a century ago, the family physician seemed about to fade out of the American medical scene. The earlier quarters of the 20th century had seen a burgeoning of scientific medicine, a proliferation of specialties and rapid refinement of medical technologies. These developments were accompanied by a notable decline of the family physician’s function. In the mid-1960s, a growing popular disenchantment with the profession’s response to the people’s need for continuing medical care was reflected by articles then appearing in such publications as Time, Life, the Saturday Review, The Wall Street Journal, Science, The New York Times Magazine, the New Republic and Harpers Monthly. The articles noted, with varying degrees of regret, resignation or approval, the approaching demise of the general practitioner.

Between April 1965 and February 1967, the Family Health Foundation of America (FHFA)–a study and development arm of AAFP’s antecedent organization, the American Academy of General Practice–sponsored with the Association of American Medical Colleges a series of conferences devoted to family practice. The conferences focused on defining family practice, developing its core curriculum and formulating plans to stimulate the establishment of family practice departments, residencies and, ultimately, a certification procedure in the specialty of family practice.

Simultaneously, three other major studies were under way: one by a national commission chaired by the late Marion Folsom, former Secretary of the then department of Health Education and Welfare; another by a citizens’ commission led by the late Dr. John Millis, president of Western Reserve, and the third by the American Medical Association’s Council on Medical Education. The reports of these three bodies converged upon the theme that individuals should have personal physicians who are the central point for integration and continuity of all medical and medically related services to their patients; recognition and status equivalent to other medical specialties should be given to family practice, and there should be a specialty board, certification examinations and diplomate status for physicians highly qualified in comprehensive care.

All these studies, and the conferences sponsored concurrently by the FHFA, were based on the recognition that in the pride of its scientific accomplishments, American medicine seemed to have lost sight of its essential objective: to provide continuing comprehensive care to the whole patient. Indeed, the Millis commission pointed out that precisely because “the science and art of medicine devoted to understanding and treating individual organs and systems have outrun the science and art of understanding and treating the whole man, specialty practice has become more necessary and more attractive.” But Sir Theodore Fox, writing in The Medical Post in 1965, suggested that the very growth of scientific medicine makes it all the more imperative that the investigator and specialist “be balanced by someone who is concerned with people rather than things.”

In a specialty commissioned report on the situation confronting family practice in the mid-1960s, I wrote: “What confronts us in medicine today is a societal monstrosity, a profession standing on its head. Its management function–its coordinator–lies at the bottom of the heap and is rapidly being ground out of existence by the pure weight and commotion of the proliferating mass of uncoordinated specialists milling about above it.”

The pyramid still stands precariously on its apex. But the specialty of family practice is gaining daily in numbers, in prestige, in popular acceptance and appreciation. Many other primary care physicians, especially general internists, are practicing what is essentially family medicine.

Bringing these revelations to present-day significance, the resource-based relative-value scale (RBRVS) study, produced under congressional mandate by William C. Hsiao, Ph.D., and colleagues at the Harvard School of Public Health, recently became the hottest topic in medical economics, stimulating a profession-wide debate.

In the midst of this debate, American Medical News reports that “the positions of the contending medical groups largely coincide with [their] financial interests.” The same source reports that each of the score or more specialists groups has retained a consultant to help it present its case.

The RBRVS formula will inevitably be revised, and special concerns, where reasonable and clear, will be accommodated. But some of the reported reactions raise the specter of a confusion of counsel or Babel of tongues such as might lead highly stressed politicians to look for a more simplistic plan for Medicare reimbursements.

The RBRVS proposal essentially offers these advantages or attractions to a free American medical profession: (1) It would seek to relate compensation to relevant factors in the costs of providing medical services. (2) It would appropriately adjust compensation for the elemental professional skills of patient care. (3) It would greatly strengthen the profession’s hand in resisting growing public pressures for federalized medicine. (4) It would render the economic practices of the profession more reasonable and logical to the people.