Falls in older persons. Causes and interventions.

Falls in older persons are an important cause of injury, disability, and death. They are also important as an indicator of decline in functional ability, requiring a careful assessment of contributing factors, in both the patient and the environment, with corrective intervention when possible. A fear of falls contributes to the problem by causing inactivity and deconditioning, further increasing the danger of falls. Identification of those at high risk and those who have begun to experience falls is important, followed by a systematic evaluation for underlying disease, medication effects, unsteady gait and balance, and environmental risk factors. Regular exercise and physical stress are also important in avoiding falls.

Physical activity counseling for healthy adults as a primary preventive intervention in the clinical setting. Report for the US Preventive Services Task Force.

Physical activity has been associated with the prevention and control of several medial conditions that are major causes of death and disability in the United States. The criterion-based approach adopted by the US Preventive Services Task Force is used to objectively evaluate the evidence regarding the effectiveness of physical activity counseling for healthy adults as a primary preventive intervention in the clinical setting. This evaluation addresses: (1) the burden of suffering attributable to physical inactivity; (2) the efficacy of physical activity in disease prevention in regard to six medical conditions; and (3) the characteristics of the intervention in terms of simplicity, cost, safety, acceptability, and patient compliance. Based on consideration of the evidence for each of these issues, specific recommendations are made regarding the role of physical activity counseling in routine clinical practice. In addition, practical guidelines are presented to aid clinicians in physical activity counseling.

Development and modification of a required family medicine clerkship.

A new required clinical clerkship in family medicine at Duke University School of Medicine is described in terms of planning, implementation, and modification in response to students' evaluations. Seventy-five percent of the eight-week course involves direct clinical experience both in academic practices and community sites, and 25 percent is spent in small group seminars and workshops. Evaluations by students have been highest for the clinical experience, the clinical competence of the faculty, the teaching effectiveness of the faculty and house staff, and the overall learning experience. The ratings have been lowest for seminars, workshops, and required written projects. Several modifications made in the clerkship over a three-year period have raised the students' ratings to near their ratings of the five traditional clerkships. The data demonstrate that family medicine can be taught effectively as a core clinical rotation and can broaden the general education of medical students.

Adherence to explicit strategies for common medical conditions.

Explicit strategies (protocols) were prepared by the staff of a primary care clinic for use as professional standards by physicians, nurse practitioners and physicians' assistants to improve care and facilitate quality assessment in cases of urinary tract infection and upper respiratory illness. Over a 2-year period, audit of 3,442 records for adherence to protocol guidelines revealed a variation with time of 38 to 100 per cent in checklist utilization and 55 to 100 per cent in compliance with specified procedures. Shifting patterns of clinic load and alterations in feedback mechanisms to providers had little relation to guideline adherence. The range in scores was attributed to patient symptom variability with subsequent difficulty applying explicit strategies, and to failure of providers to record details contributing to clinical decisions. With this range of "success" following self-imposed predefined strategies, it is not surprising that retrospective record reviews using short sample periods and criteria established by outside expert panels document wide variation in quality.

Standards for practice: effectiveness and acceptance.

Carefully designed and highly specific standards for medical practice can improve the pattern of practice when applied by interested and committed physicians or by other similarly motivated health care providers. However, this is not popular with the physician, and the improved pattern of practice is dependent on continued feedback. The standards must be designed with a specific population and setting in mind; therefore it is unlikely that an effective operational plan can be devised and implemented that will achieve improved practice patterns in the immediate future. Meanwhile, more general standards might be used to identify a smaller number of cases, which can then be reviewed by other physicians, using professionally accepted but subjective practice criteria.

A manpower policy for primary health care.

A National Academy of Sciences study of policy options for the supply of primary health-care manpower has produced a comprehensive set of recommendations. The study finds an adequate overall supply of physicians, but a shortage of primary health-care practitioners. It recommends maintaining current enrollment levels in medical schools and training programs for nurse practitioners and physician assistants and increasing the proportion of primary-care residents. To enhance the availability of primary care, the report advocates reimbursement for all physicians within a state at the same payment level for the same primary-care service, a reduction in payment differentials between primary-care services and nonprimary-care services, and reimbursement for educational and preventive services and for new health-practitioner services. The report supports a team approach in primary-care training and recommends that all medical students obtain clinical experience in a primary-care setting and some instruction in epidemiology and behavioral and social sciences.

A plan to put primary-care doctors in the driver's seat. Interview by Richard L. Peck.

The Institute of Medicine has developed a report outlining a plan to produce more primary-care physicians; reimbursement of commonly accepted health education and preventive medicine procedure is proposed. Dr. E. Harvey Estes, Chairman of the Study Team, reviews the recommendations offered by the Institute to achieve this goal. The Institute directs many of its suggestions at restructuring the reimbursement system. If the federal, state and private organizations reimbursed primary care physicians and specialists on a more equal scale, regardless of geographic location, there would be more incentive for new doctors to enter primary care and to practice in underserved communities. Third-party payors are encouraged to reimburse physicians and physician extenders at the same rate to reinforce the fact that they are all part of a practice team. In addition, it is recommended that third-parties reduce the number of fractional reimbursements and bureaucratic delays that currently take place. Estes concludes that primary care should have sufficient financial incentive to attract and maintain well-trained physicians.