Identifying physicians likely to benefit from depression education: a challenge for health care organizations.

BACKGROUND: Few methods exist to identify physicians who might benefit from depression education. OBJECTIVES: To develop a measure of physicians' confidence or self-efficacy in caring for depressed patients and assess it's reliability and validity. RESEARCH DESIGN: A national sample of primary care physicians were surveyed and exploratory factor analysis (EFA) was used to identify factors underlying physicians' responses to 26 items. We named the factors, selected items with factor loadings > or = 0.50 for final scales, and tested a priori hypotheses about self-efficacy. SUBJECTS: 1) Random cross-sectional sample of family physicians, internists, obstetrician-gynecologists, and pediatricians (n = 5,369) and 2) 49 general internists and family physicians participating in a prepost evaluation of a depression workshop. RESULTS: In the national sample, 3,712 physicians were eligible and 2,104 responded. Forty-six percent were female, and 51% were family physicians and general internists. EFA identified 5 factors, the first of which was called Self-Efficacy (4 items, alpha = 0.86). More family physicians (64%) had confidence (self-efficacy) in caring for depressed patients compared with general internists (33%), obstetrician-gynecologists (16%), and pediatricians (6%) (P < 0.001). Few physicians intended to change their care of depressed patients (10%) or take CME on depression (24%). Of the 49 physicians attending a depression workshop, 76% reported high self-efficacy after the workshop versus 50% before it (P = 0.013). CONCLUSIONS: This study supports the reliability and validity of the Self-Efficacy scale as one method to identify physicians who might benefit from interventions. New approaches are needed because physicians are unlikely to change.

Primary care pediatricians' roles and perceived responsibilities in the identification and management of depression in children and adolescents.

OBJECTIVE: To describe primary care pediatricians' 1) approach to the identification and management of childhood and adolescent depression and 2) perception of their skills, responsibilities, and barriers in recognizing and managing depression in children and adolescents. DESIGN AND METHODS: National cross-sectional survey of randomly selected primary care pediatricians that assessed the management of recalled last case of child or adolescent depression, attitudes, limitations to care from barriers and skills, and willingness to implement new educational or intervention strategies to improve care. RESULTS: There were 280 completed surveys about child and adolescent depression (63% response rate). Pediatricians overwhelmingly reported it was their responsibility to recognize depression in both children and adolescents (90%) but were unlikely to feel responsible for treating children or adolescents (26%-27%). Those with most of their practice in capitated managed care were less likely to feel responsible for recognizing depression in either children or adolescents. Forty-six percent of pediatricians lacked confidence in their skills to recognize depression in children, and few of them (10%-14%) had confidence in their skills in different aspects of treatment with children or adolescents. Diagnostic, assessment, and management details for their last recalled case of depression in a child or adolescent were provided by 248 of these pediatricians. In addition to referring 78%-79% of the cases to mental health care professionals, 77% of pediatricians provided a wide range of brief interventions. Only 19%-20% prescribed medication. Major factors cited that limited their diagnosis or management were time (56%-68%) and training or knowledge of issues (38%-56%). Fewer pediatricians noted limitations due to insurer or financial issues (8%-39%) or patient issues (19%-31%). The 35% of pediatricians who were motivated to change their recognition and management of suspected depression were significantly more interested in implementing in the future a variety of new strategies to improve care. CONCLUSION: Primary care pediatricians felt responsible for recognizing but not for treating child and adolescent depression. Although the lack of confidence and lack of knowledge and/or skills and time issues are major barriers that limit pediatricians in their treatment of childhood and adolescent depression, pediatricians varied in their readiness to change, with some being more willing to implement new strategies to care for depression. Educational and practice interventions need to focus on how to assist all pediatricians in diagnosis and to prepare these motivated pediatricians to manage depression in primary care settings.

Persistent increase in children's sun protection in a randomized controlled community trial.

BACKGROUND: Reducing sun exposure during childhood may prevent skin cancer later in life. Sun protection increased immediately following implementation of the SunSafe multicomponent, community-based intervention delivered in 1996 through schools, day care centers, primary care offices, and beach recreation areas. Whether sun protection levels would remain higher than preintervention levels the following summer was unknown. METHODS: A randomized controlled trial based in 10 New Hampshire towns addressed children's use of protective clothing, shade, and sunscreen at freshwater beach areas. The intervention was provided initially between March and May 1996. A brief project follow-up contact was provided to schools, day care centers, beaches, and primary care offices between March and May 1997 to restock intervention materials and to answer questions. Observations of 1490 children during June through August of 1997 were compared with observations made prior to any intervention between June and August of 1995. RESULTS: In intervention towns, the proportion of children using at least some sun protection increased by 0.15 from 0.58 in 1995 to 0.73 in 1997 while the proportion in control towns increased by 0.03 (P = 0.033). This increase was due to more use of sunscreen, but not more use of protective clothing or shade. In 1997, care-givers of children in intervention towns reported receiving more sun protection information from school and health care sources than control town caregivers (62% versus 33%, P < 0.006). CONCLUSIONS: In intervention communities, a higher proportion of children used sun protection in 1997 than at baseline. Increases from 1995 to 1997 were similar in magnitude to short-term increases between 1995 and 1996 that we have been previously reported.

Differences in ambulatory teaching and learning by gender match of preceptors and students.

BACKGROUND AND OBJECTIVES: Important differences exist in traditional medical education by gender of the teachers and learners. Much less is known about how gender influences educational experiences in community-based ambulatory settings. In this study, we explored how community-based teaching and learning varies by gender of the students and preceptors. METHODS: This prospective study used both paper- and computer-based documentation systems to collect information on student-patient-preceptor encounters. A consecutive sample of third-year medical students contributed data on one full clinical day each week as they rotated through a required 8-week family medicine clerkship. The main measures of interest included patient age and gender, health care visit type (acute, acute exacerbation of chronic, chronic, and health maintenance), method of learning in history taking and physical examinations (observing preceptor, being observed by preceptor, performing unobserved, or working jointly with preceptor), content of physical examinations, amount of preceptor feedback, preceptor teaching content, and gender of the students and their preceptors. RESULTS: Ninety-three students contributed data on 5,017 patient encounters. The distribution of encounters by student-preceptor dyad included: 1,926 (38%) female students with male preceptors. 1,716 (34%) male students with male preceptors, 841 (17%) female students with female preceptors, and 534 (11%) male students with female preceptors. We found that female preceptors conduct more complete physical exams with students than do male preceptors (28% versus 23%). Female students with male preceptors devoted more encounters to observation only than any other dyad (20% versus 12%), and female preceptors are more likely than male preceptors to allow students to perform unobserved (70% versus 59%). Patient gender played little if any role in how students and their preceptors worked together. CONCLUSIONS: Differences of potential importance were found in teaching and learning by gender of the student-preceptor dyad. This factor can and should be considered when determining how students can best meet educational objectives in community-based ambulatory settings.

The depression in primary care tool kit.

OBJECTIVE: A tool kit was developed to help primary care physicians overcome some of the barriers to recognition and management of depression. METHOD: Tools were collected from a variety of sources, categorized by function, and evaluated on the basis of previously established criteria, with the best tools selected for inclusion in the tool kit. New tools were developed when an adequate tool for a desired function was not available. The tool kit was reviewed and then revised based on the feedback from eleven experts on depression in primary care, five medical directors from health care systems or managed care companies, and eighteen primary care physicians. All eighteen primary care physicians completed a questionnaire after reviewing the tool kit as part of the evaluation process. RESULTS: Only five of the eighteen physicians were using any kind of tool for depression prior to reviewing the tool kit. All eighteen physicians indicated that they were likely to use one or more of the components of the tool kit. On average, physicians indicated they were likely to use 6.5 of the ten types of tools included in the kit. CONCLUSIONS: A depression tool kit containing screening, diagnostic, management planning, and outcomes assessment questionnaires as well as treatment and counseling guidelines, information tables, flow charts, and patient education materials is likely to be well received by primary care physicians. However, its effectiveness may have as much to do with how its use is organized and implemented as it does with the intrinsic value of its components.

Office systems intervention to improve diethylstilbestrol screening in managed care.

OBJECTIVE: To examine the effectiveness of a comprehensive office systems intervention for improving identification of diethylstilbestrol (DES) exposure, a low-incidence condition with potentially severe consequences. METHODS: We developed a comprehensive office systems intervention to facilitate screening and follow-up for women exposed to DES in utero, consisting of a DES toolkit and the clinical and administrative education necessary to use the tools effectively. The intervention was implemented in the internal medicine and obstetrics-gynecology departments at six free-standing health centers in a Boston-area staff-model health maintenance organization. Intervention sites were matched and paired with a comparison group of centers. Intervention effectiveness was assessed through pretest and posttest surveys of clinicians, medical record review of 3900 women, and review of a computerized medical records data base. RESULTS: There was significantly higher DES awareness and knowledge among clinical staff at intervention sites. Documentation of DES exposure in the medical record ranged from 1.14 to 2.31 times greater at intervention sites than in matched comparison sites, and rates of DES code use in pregnancy were 1.91 to 3.61 times greater. CONCLUSIONS: The office systems intervention improved documentation of DES exposure in a managed care environment. Because this approach was designed to accommodate the limited time allotted for each patient visit, it not only improved DES screening but could also serve as a model for integrating screening for other low-prevalence but potentially serious conditions into routine care.

Referrals to psychiatrists. Assessing the communication interface between psychiatry and primary care.

The Study of Outpatient Referral Patterns was conducted in 1998 to examine the nature of the communication relationship between psychiatrists and primary care physicians regarding outpatient referrals. Nationally representative psychiatrists were surveyed (N = 542) regarding their aggregate experience with outpatient referrals from non-psychiatric physicians in the previous 60 days. Data regarding frequency and type of information and mode of communication were gathered. Results indicate that primary care physicians represent a significant source of referrals to psychiatrists and that psychiatrists are generally satisfied with the communication interface with the referring physicians. Psychiatrists' level of satisfaction was related to the quantity and quality of information provided by referring physicians.

Interventions to improve provider diagnosis and treatment of mental disorders in primary care. A critical review of the literature.

The authors conducted a critical review of the literature on interventions to improve provider recognition and management of mental disorders in primary care, searching the MEDLINE database for relevant articles published from 1966 through May 1998 and finding 48 usable controlled studies (27 randomized controlled trials and 21 quasi-experimental studies). Improved diagnosis of mental disorders was reported in 18 of 23 (78%) of the studies examining this outcome and improved treatment in 14 of 20 studies (70%); clinical improvement in psychiatric symptoms or functional status was documented in 4 of 11 and 4 of 8 (36% and 50%, respectively). Considerable study heterogeneity precluded subjecting the literature synthesis to a formal meta-analysis of pooled results; the authors were therefore unable to demonstrate an association between efficacy of an intervention and any specific variables. A variety of interventions and further research may be effective in improving the recognition and management of mental disorders in primary care.

Sun protection counseling for children: primary care practice patterns and effect of an intervention on clinicians.

OBJECTIVES: To describe current primary care sun protection advice for children and assess the effect on clinicians of an intervention to enhance their sun protection advocacy. SETTING: Primary care practices caring for children in New Hampshire with special attention to clinicians serving 10 towns that were involved in a randomized controlled trial of the multicomponent SunSafe intervention involving schools, recreation areas, and primary care practices. DESIGN/INTERVENTION: A statewide survey of all primary care clinicians serving children addressed their self-reported sun protection advocacy practices. Clinicians in 10 systematically selected rural towns were involved in the subsequent intervention study. The primary care intervention provided assistance to practices in establishing an office system that promoted sun protection advice to children and their parents during office visits. MAIN OUTCOME MEASURES: Sun protection promotion activities of primary care clinicians as determined by their self report, research assistant observation, and parent interviews. RESULTS: Of 261 eligible clinicians responding to the statewide survey, about half provide sun protection counseling "most of the time" or "almost always" during summer well care visits. Pediatricians do so more often than family physicians. Clinicians involved in the intervention increased their use of handouts, waiting room educational materials, and sunscreen samples. Compared with control town parents, parents in intervention towns reported an increase in clinician sun protection advice. CONCLUSIONS: The SunSafe primary care intervention increased sun protection counseling activities of participating clinicians. A single-focus preventive service office system is feasible to include in community interventions to promote sun protection.

An encounter-based analysis of the nature of teaching and learning in a 3rd-year medical school clerkship.

BACKGROUND: Much of medical education has shifted from the hospital to ambulatory settings where each student works with a preceptor. PURPOSE: Our objectives were to describe the nature of community-based learning and to explore how learning experiences vary by type of health care visit. METHODS: This prospective study used both paper- and computer-based documentation systems to collect information on student-patient-preceptor encounters. A consecutive sample of 3rd-year medical students contributed data on 1 full clinical day each week as they rotated through a required 8-week family medicine clerkship. The main measures of interest included patient age, gender, health care visit type (acute, acute exacerbation of chronic, chronic, and health maintenance), method of learning in history taking and physical examinations (observing preceptor, being observed by preceptor, performing unobserved, or working jointly with preceptor), content of physical examinations, amount of preceptor feedback, and preceptor teaching content. RESULTS: Sixty-three students contributed data on 4,083 patient encounters. The majority of visits concerned acute complaints (37.7%) or health maintenance (26.4%). Many encounters involved students conducting the cardiovascular and pulmonary exams (33.2% each); fewer encounters involved neurologic (6.9%), gynecological (4.5%), and genitourinary (2.2%) exams. Students reported being observed performing histories and physical exams in 4% and 6% of encounters respectively. The most common student experiences were performing histories and performing physical exams unobserved during acute visits, which accounted for 65.8% and 52.4% of encounters overall. CONCLUSIONS: This system is useful for determining educational content and processes that occur in ambulatory settings. Important differences were found in teaching and learning by type of health care visit. This factor can and should be used when considering how students meet educational objectives in community-based ambulatory settings.

Improved access to women's health services for Alaska natives through community health aide training.

This project demonstrates the effect of increasing the skills of Community Health Aides (CHAs) on the use of specific preventive health services by women in remote Alaska villages. Eight CHAs were trained in specimen collection for Pap and sexually transmitted disease testing, and in clinical breast examination. Skill competency was monitored. Computerized medical records of all women between the ages of 18 and 75 in the four villages with trained CHAs and in four comparison villages (n = 1093) were checked for Pap status prior to CHA training and again 12 months later. All eight CHAs achieved competency and provided services in their village clinics with telephone support from an experienced clinician. The post-training year Pap test rate of women who were overdue for a Pap test was 0.44 in the villages with trained CHAs; the rate among the women in the comparison villages was 0.32 (p = .079).

Promoting sun protection in elementary schools and child care settings: the SunSafe Project.

Elementary schools and child care settings in rural New Hampshire participated in a sun protection program that reached more than 4,200 children. The program was part of a successful multifaceted community intervention targeting children ages 2-9. Program components included curricular materials, training and support for school/child care staff, and parent outreach. Evaluation showed good uptake of the curriculum by teachers and child care providers, improvements in sun protection policy in participating schools and child care settings, and significant knowledge and attitude improvements in fourth grade children tested, as well as actual behavior change. The study highlighted the importance of flexible, developmentally appropriate curricular materials and active engagement of principals and directors in policy review. In addition, for parent outreach programs to be successful, children needed to participate.

CART: a controlled algebraic reconstruction technique for electron microscope tomography of embedded, sectioned specimen.

Reconstruction of thick, embedded, sectioned material has to cope with the restricted tilt view of the electron microscope, with information not stemming from the object of interest in the projections, with aberrations of the objective lens and with a distorted relationship between the projected densities in the micrographs and the specimen mass densities due to incoherent electron interactions within the specimen. Micrograph densities over a full tilt-range show in general an averaged mass increase which is more than should be expected from the cosine dependency of the tilt-angles of the projections. The hereby presented reconstruction technique finds a solution for the under-determined system by a controlled algebraic iteration procedure. For this solution the procedure stabilises the region of interest by dynamically scaling the input data during the procedure. A model for the electron transport through thick specimens is proposed and microscope projection simulations are carried out to test the algorithms.

Primary care physicians' approach to depressive disorders. Effects of physician specialty and practice structure.

BACKGROUND: Because primary care physicians (PCPs) are the initial health care contact for most patients with depression, they are in a unique position to provide early detection and integrated care for persons with depression and coexisting medical illness. Despite this opportunity, care for depression is often suboptimal. OBJECTIVE: To better understand how to design interventions to improve care, we examine PCPs' approach to recognition and management and the effects of physician specialty and degree of capitation on barriers to care for 3 common depressive disorders. METHODS: A 53-item questionnaire was mailed to 3375 randomly selected subjects, divided equally among family physicians, general internists, and obstetrician-gynecologists. The questionnaire assessed reported diagnosis and treatment practices for each subject's most recent patient recognized to have major or minor depression or dysthymia and barriers to the recognition and treatment of depression. Eligible physicians were PCPs who worked at least half-time seeing outpatients for longitudinal care. RESULTS: Of 2316 physicians with known eligibility, 1350 (58.3%) returned the questionnaire. Respondents were family physicians (n = 621), general internists (n = 474), and obstetrician-gynecologists (n = 255). The PCPs report recognition and evaluation practices related to their most recent case as follows: recognition by routine questioning or screening for depression (9%), diagnosis based on formal criteria (33.7%), direct questioning about suicide (58%), and assessment for substance abuse (68.1%) or medical causes of depression (84.1%). Reported treatment practices were watchful waiting only (6.1%), PCP counseling for more than 5 minutes (39.7%), antidepressant medication prescription (72.5%), and mental health referral (38.4%). Diagnostic evaluation and treatment approaches varied significantly by specialty but not by the type of depression or degree of capitation. Physician barriers differed by specialty more than by degree of capitation. In contrast, organizational barriers, such as time for an adequate history and the affordability of mental health professionals, differed by degree of capitation more than by physician specialty. Patient barriers were common but did not vary by physician specialty or degree of capitation. CONCLUSIONS: A substantial proportion of PCPs report diagnostic and treatment approaches that are consistent with high-quality care. Differences in approach were associated more with specialty than with type of depressive disorder or degree of capitation. Quality improvement efforts need to (1) be tailored for different physician specialties, (2) emphasize the importance of differentiating major depression from other depressive disorders and tailoring the treatment approach accordingly, and (3) address organizational barriers to best practice and knowledge gaps about depression treatment.

Improving the recognition and management of depression: is there a role for physician education?

BACKGROUND: Many patients who visit primary care physicians suffer from depression, but physicians may miss the diagnosis or undertreat these patients. Improving physicians' communication skills pertaining to diagnosing and managing depression may lead to better outcomes. METHODS: We performed a randomized controlled trial involving 49 primary care physicians to determine the effect of the Depression Education Program on their knowledge of depression and their behavior toward depressed patients. After randomization, physicians in the intervention group completed the Depression Education Program, which consists of 2 4-hour interactive workshops that combine lectures, discussion, audiotape review, and role-playing. Between sessions, physicians audiotaped an interview with one of their patients. Two to 6 weeks following the intervention program, physicians completed a knowledge test and received office visits from 2 unannounced people acting as standardized patients with major depression. These "patients" completed a checklist and scales. Logistic and linear regression were used to control for sex, specialty, and suspicion that the patient was a standardized patient. RESULTS: For both standardized patients, more intervention physicians than control physicians asked about stresses at home, and they also scored higher on the Participatory Decision-Making scale. During the office visits of one of the standardized patients, more intervention physicians asked about at least 5 criteria for major depression (82% and 38%, P = .006), discussed the possibility of depression (96% and 65%, P = .049), scheduled a return visit within 2 weeks (67% and 33%, P = .004), and scored higher than control physicians on the Patient Satisfaction scale (40.3 and 35.5, P = .014). CONCLUSIONS: The Depression Education Program changed physicians' behavior and may be an important component in the efforts to improve the care of depressed patients.