¿Es la familia una realidad en la medicina familiar? / Is the family a reality in family practice?

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Two physician styles of focusing on the family.

BACKGROUND: Previous research has identified 2 styles of family physicians' focus on the patient's family: (1) using the family history as the context of care of the patient; and (2) maintaining a family orientation with the family as the unit of care. The purpose of our study was to determine whether these styles affect patient outcomes and time use during outpatient visits. METHODS: In a cross-sectional study, data on 4454 outpatient visits to 138 community family physicians were collected using direct observation, patient and physician questionnaires, and medical record review. We computed partial correlations between the physician's family practice style score and patient outcomes for delivery of preventive services, patient visit satisfaction, and patient-reported delivery of specific components of primary care. We controlled for relevant patient characteristics. RESULTS: The patients of the physicians using either practice style had similar levels of satisfaction with coordination of care and interpersonal communication, and their value of continuity of care was comparable. Patients of physicians with a family-history style, however, rated their physicians lower on a measure of in-depth knowledge of the patient and family but higher on preventive services delivery. Differences in time use during the visit reflected how these styles were manifested during the outpatient visit. CONCLUSIONS: The different styles physicians use to focus on the family affect the process and outcomes of patient care. This difference may be explained by the developmental life cycle of family physicians, as younger physicians may be more focused on family history and older physicians may have a more family-oriented focus. Physicians may need to find alternate ways of meeting those patient needs not well met by their predominant practice style.

A personal research odyssey.

The Journal of Family Practice is pleased to publish the acceptance speech of Dr Jack Medalie, the 1998 recipient of the Maurice Wood Award for Lifetime Contribution to Primary Care Research. This address was delivered on November 6, 1998, at the 26th Annual Meeting of the North American Primary Care Research Group (NAPCRG) in Montreal. This prestigious annual award honors the person who has, throughout his or her career, made the greatest contribution to primary care research and related fields. Researchers from all nations, working in all professional and scientific disciplines are eligible to receive the award. The award is named in honor of Dr Maurice Wood, an early pioneer and leader in primary care research in North America and founder of NAPCRG. The Wood Award is supported by donations from friends of primary care research across North America and around the world. For more information, contact NAPCRG at: PO Box 8729, Kansas City, Missouri 64114; 1-800-274-2237; E-mail: napcrg@stfm.org.

Illuminating the 'black box'. A description of 4454 patient visits to 138 family physicians.

BACKGROUND: The content and context of family practice outpatient visits have never been fully described, leaving many aspects of family practice in a "black box," unseen by policymakers and understood only in isolation. This article describes community family practices, physicians, patients, and outpatient visits. METHODS: Practicing family physicians in northeast Ohio were invited to participate in a multimethod study of the content of primary care practice. Research nurses directly observed consecutive patient visits, and collected additional data using medical record reviews, patient and physician questionnaires, billing data, practice environment checklists, and ethnographic fieldnotes. RESULTS: Visits by 4454 patients seeing 138 physicians in 84 practices were observed. Outpatient visits to family physicians encompassed a wide variety of patients, problems, and levels of complexity. The average patient paid 4.3 visits to the practice within the past year. The mean visit duration was 10 minutes. Fifty-eight percent of visits were for acute illness, 24% for chronic illness, and 12% for well care. The most common uses of time were history-taking, planning treatment, physical examination, health education, feedback, family information, chatting, structuring the interaction, and patient questions. CONCLUSIONS: Family practice and patient visits are complex, with competing demands and opportunities to address a wide range of problems of individuals and families over time and at various stages of health and illness. Multimethod research in practice settings can identify ways to enhance the competing opportunities of family practice to improve the health of their patients.

The family in family practice: is it a reality?

BACKGROUND: The purpose of this study was to describe, from multiple perspectives, the extent to which community family physicians focus on the family. METHODS: In a cross-sectional study, research nurses directly observed consecutive patient visits for 2 days in the offices of 138 community family physicians. Data were collected on 4454 outpatient visits using direct observation, patient and physician questionnaires, and medical record review. Descriptive statistics were calculated, and a factor analysis was used to identify subsets of correlated family focus descriptors. RESULTS: On average, 10% of the time intervals during patient visits was devoted to addressing family issues. Other family members were present during 32% of visits, and another family member's problems were discussed in 18% of visits. Seventy percent of patients reported that other family members see the same doctor. A family history was obtained during 51% of visits by new patients and 22% of visits by established patients. Genograms were present on 11% of charts and family folders were seldom used. The presence or absence of a family history of breast or colon cancer was noted in 40% of charts. A factor analysis identified two different physician styles: family history as a context for care of an individual patient, and the family as the unit of care. The latter approach correlated with the patient's assessment that the doctor knew their families. CONCLUSIONS: Family physicians show a high degree of emphasis on the family, and exhibit two different styles of family focus in community practice. The effects of these different approaches to family care on patient outcomes is an important area for future research.

The patient and family adjustment to chronic disease in the home.

The increase in chronic disease with shortened hospitalizations has led to an increase in home care, with added adjustment problems for patients and their families. The majority of families cope satisfactorily, although most have periods of instability or difficulties which require appropriate support. In considering the impact of chronic illness, cognizance must be taken of the patient, the illness, the caregiving system, the medical care system, the interrelationship between them and the effect of the environment on all of them. The adjustment to chronic illness depends on the complementary meshing of the life and time cycles of the above factors during the alternating periods of crises and chronic maintenance. It is apparent that, in a pluralistic multicultural society, a broad range of diverse family forms and functioning is compatible with adjustment to a member with chronic disease. Finally, a scheme for the medical team's assessment and care is presented.

Intermittent claudication in 8343 men and 21-year specific mortality follow-up.

PURPOSE: As Western populations live longer, peripheral vascular disease will become a greater individual and public health problem. Therefore, the long-term natural history of intermittent claudication (IC) needs further delineation. The study objective was to describe the 21-year mortality and relative risk for cause-specific mortality for subjects with incident IC. METHODS: The subjects were 8343 Israeli male governmental employees aged 40-65 years who were free of coronary heart disease and symptomatic peripheral vascular disease in 1963. These men were followed for 21 years to measure differences in mortality between those who did and did not develop incident IC. Incident IC was diagnosed in 1965 and 1968 by the London School of Hygiene IC Questionnaire. All other cardiovascular disease risk factors were measured by standardized and validated procedures. Cause-specific mortality through 1986 was determined through death certificates from the Israeli Mortality Register. RESULTS: A total of 360 men with IC and 7983 symptom-free men were followed for survival from 1965 to 1986; 159 men with IC (44%) and 2330 symptom-free men (29%) died. For total mortality, the Kaplan-Meier 21-year survival probabilities were 56% for IC and 71% for symptom-free men (P < 0.0001 for the entire 21-year survival difference between the two groups). For coronary heart disease (CHD), stroke, and other causes of death, the survival probabilities for men with IC and symptom-free men were, respectively: 85% vs. 90%, 89% vs. 97%, and 79% vs. 83% (P = 0.0004; P < 0.0001; and P = 0.007, respectively, for the entire 21-year survival difference between the two groups). Cox's proportional hazards model was used to control confounding from incident myocardial infarction and angina through 1968, as well as for demographic, physiologic, psychosocial, and other cardiovascular disease risk factors. The 21-year adjusted all-cause mortality relative risk for IC was 1.50 (95% confidence interval (CI), 1.28-1.77). For stroke deaths the relative risk was 2.76 (95% CI, 1.89-4.02). For stroke mortality, IC was the third strongest predictor of death after elevated systolic blood pressure and increasing age. Incident IC had a relative risk of CHD deaths of 1.31, but it was not statistically significant (P = 0.08; 95% CI, 0.97-1.77). IC was not statistically significantly related to other causes of death (P = 0.10) after adjustment for covariates. CONCLUSIONS: IC is strongly predictive of long-term cerebrovascular disease mortality among men. Incident IC is a stronger indicator of cerebrovascular than of CHD death.

Isolated low HDL cholesterol as a risk factor for coronary heart disease mortality. A 21-year follow-up of 8000 men.

For the purpose of screening individuals at high risk for coronary heart disease (CHD), serum total cholesterol (TC) of 5.2 mmol/L, has been set as a value dividing "desirable" from intermediate high or elevated levels, and HDL cholesterol (HDL-C) < 0.9 mmol/L has been labeled as abnormally low, implying high CHD risk. It has been conjectured that low HDL-C poses no risk in the absence of elevated LDL cholesterol or TC. To assess the risk of CHD-free men with "isolated low HDL-C," ie, abnormally low HDL-C with desirable TC, we examined the CHD and all-cause mortality of some 8000 Israeli men aged 42 years and older during 1965 through 1986. Men with isolated low HDL-C represented one sixth of the cohort. CHD mortality among these men was 36% higher (age adjusted) than in counterparts with desirable TC, of which > 0.9 mmol/L was contained in the high-density fraction. In men with TC > 5.2 mmol/L, abnormally low HDL-C was associated with a virtually identical CHD mortality risk ratio, 38%. These findings persisted after adjustment for multiple CHD risk factors. The excess CHD risk associated with isolated low HDL-C appeared particularly increased in men with diabetes mellitus, whose death rate was 65% higher than in diabetics with HDL-C > 0.9 mmol/L. A second subgroup result was consistent with equal CHD mortality risk among men in the "desirable" TC range, with or without low HDL-C, if systolic blood pressure was > 160 mm Hg. These are post hoc findings, and hypotheses arising from these observations would require independent examination. Total mortality was not increased in men with isolated low HDL-C compared with men who had HDL-C < 0.9 mmol/L and TC > 5.2 mmol/L at baseline. These results indicate that an increased risk of CHD death is associated with abnormally low HDL-C for cholesterol ranges both below and above 5.2 mmol/L. For the individual, therefore, the risk is multiplied by the same amount regardless of TC. Quitting smoking, increasing physical activity, and decreasing body weight would all contribute to raise HDL-C in individuals of most or all age groups. When examined from a community perspective, the results are consistent with a relatively low population-attributable fraction among CHD-free men. This would tend to support the recommended practice of considering a TC level of 5.2 mmol/L (200 mg/dL) as a threshold for further evaluation in screened individuals without manifest CHD.

Self-reported physical activity predicts long-term coronary heart disease and all-cause mortalities. Twenty-one-year follow-up of the Israeli Ischemic Heart Disease Study.

OBJECTIVE: To determine whether self-reported physical activity predicts a decreased rate of coronary heart disease (CHD) and all-cause mortalities in middle-aged men when rates are adjusted for known confounders. DESIGN: Cohort Analytic Study of Israeli government employees in 1963. SUBJECTS: Eight thousand four hundred sixty-three Israeli male government employees, aged 40 years or older, representing six areas of birth, excluding those with known cardiovascular disease in either 1963 or 1965, from an original cohort of 10,059. MAIN OUTCOME MEASURE: Comparison of rates of death due to CHD and all causes, determined from death certificates in 21 years of follow-up, for subjects with different baseline levels of self-reported leisure-time and work-related physical activities measured in 1965. RESULTS: Self-reported leisure-time but not work-related physical activity was inversely related to both CHD (adjusted relative risk, 0.79; 95% confidence interval, 0.66 to 0.95) and all-cause mortalities (adjusted relative risk, 0.91; 95% confidence interval, 0.83 to 0.99). Most of the apparent benefit accrued was from light physical activity on less than a daily basis. These inverse relationships persisted after adjustment for age, systolic blood pressure, cigarette smoking, total and high-density lipoprotein cholesterol levels, body mass index, psychosocial factors, and other potential confounders. CONCLUSION: Baseline levels of self-reported leisure-time physical activity predicted a decreased rate of CHD and all-cause mortalities in employed middle-aged Israeli men followed up prospectively for 21 years.

Epidemiology of intermittent claudication in middle-aged men.

Intermittent claudication, myocardial infarction, and angina pectoris share many epidemiologic and biologic features. Yet few large cohort studies describing the prevalence, incidence, and risk factors for intermittent claudication have been done. The authors evaluated intermittent claudication in 10,059 Israeli men aged 40-65 years, of whom 8,343 were free of coronary heart disease and symptoms of peripheral vascular disease; this latter group was followed for 5 years from 1963 to 1968. Prevalent and incident cases of intermittent claudication were defined by the London School of Hygiene Cardiovascular Disease Questionnaire, and all cardiovascular disease risk factor evaluations were standardized. Baseline prevalence was 27.0/1,000 (211/10,029). A total of 360 previously healthy men developed intermittent claudication for a crude 5-year incidence rate of 43.1/1,000 (360/8,343) or a crude annual incidence of 8.6/1,000. Following univariate analysis with demographic, physiologic, psychosocial, and other cardiovascular disease variables, logistic regression was used to identify risk factors for intermittent claudication. These were the following: > 20 cigarettes per day, odds ratio (OR) = 2.02, 95% confidence interval (CI) 1.54-2.66; serum cholesterol (50-mg/dl difference), OR = 1.35, 95% CI 1.18-1.54; 11-20 cigarettes per day, OR = 1.69, 95% CI 1.24-2.30; anxiety (high vs. low), OR = 1.85, 95% CI 1.29-2.65; socioeconomic status, OR = 1.82, 95% CI 1.26-2.64; and diabetes, OR = 1.85, 95% CI 1.25-2.75. Other significant predictors of smaller magnitude included in the regression were age, psychosocial coping factors, Quetelet's index, and exsmoking. The risk factors for intermittent claudication were a blend of those related to myocardial infarction (smoking, cholesterol, diabetes, but not hypertension) and others related to angina pectoris but not to myocardial infarction (stress and coping variables). There is reason to believe that preventing or modifying these factors will prove effective in altering the natural history and clinical outcomes of peripheral vascular disease as shown in other forms of atherosclerosis.

Twins: double pleasure or double trouble?

The birth of twins can be an exciting and challenging experience for a family. However, circumstances unique to the relationship between the twin and the family and the relationship between the twins themselves may exacerbate existing problems or create new ones. Parents are often overwhelmed by the amount of time and work involved in caring for the twins, and other siblings may feel excluded from the family. Twins themselves may have difficulties with processes such as individuation and bonding with other family members. With supportive anticipatory guidance, physicians can help parents and siblings of newborn twins adjust to the special circumstances that the birth of twins can bring.

Long-term mortality of Nazi concentration camp survivors.

Nazi concentration camp survivors have been shown to have excess mortality in the first 20 years following their release. To determine if this excess persists, Israeli civil servants were studied. Mortality of camp survivors and of other post-war European immigrants was compared 20-41 years following World War II. Using survival analysis and proportional hazards models, no difference in mortality rates was found.

Factors predictive of long-term coronary heart disease mortality among 10,059 male Israeli civil servants and municipal employees. A 23-year mortality follow-up in the Israeli Ischemic Heart Disease Study.

Over 10,000 male civil servants and municipal employees in Israel, aged 40 years and above, underwent an extensive clinical, biochemical, anthropometric, sociodemographic and psychosocial evaluation in 1963, 1965 and 1968. Follow-up for mortality was continued through 1986. Over 23 years, a number of previously established risk factors for coronary heart disease (CHD) incidence were found to predict mortality. The long-term follow-up assisted in illustrating temporal patterns. A single causal assessment of blood pressure retained high prediction for long-term mortality. Blood lipids, while significantly associated with both coronary and all-cause mortality, exhibited a small contribution to the latter, when compared to hypertension, cigarette smoking habits and diabetes. Weak associations of long-term coronary mortality with the dietary intake patterns of fatty acids, as reported at baseline, were probably fully mediated by the effect of the diet on serum cholesterol. Religious orthodoxy appeared to provide a degree of immunity, part of which was independent of life-style correlates. A number of now well-established associations in cardiovascular epidemiology were first demonstrated, or amplified, in the study. Patterns of ethnic diversity in the risk factor and prevalence rates of CHD persisted, as viewed from the angle of mortality rates, over nearly a quarter of a decade, highlighting the enigma of a migrant country as a cardiovascular melting pot.

The importance of biopsychosocial factors in the development of duodenal ulcer in a cohort of middle-aged men.

This study prospectively evaluated psychosocial as well as biologic, behavioral, and demographic factors in the development of duodenal ulcer. Baseline data were collected in 1963 on 8,458 Israeli men over age 40 years who had no history of duodenal ulcer. The subjects were followed for 5 years, and 254 reported the development of radiographically proven duodenal ulcer. The average annual incidence was six per 1,000 subjects. Multivariable logistic regression analysis confirmed several previously reported risk factors: smoking (odds ratio (OR) = 1.64, 95% confidence interval (Cl) 1.25-2.16), greater age (60 years and over) (OR = 1.85, 95% Cl 1.25-2.74), lower salary (OR = 1.50, 95% Cl 1.14-1.96), and lower systolic blood pressure (less than 140 mmHg) (OR = 1.58, 95% Cl 1.16-2.15). In addition, logistic regression analysis revealed a significant association of duodenal ulcer incidence with preceding measures of family stress, emotional support, and coping style. These were: increased family problems (OR = 1.60, 95% Cl 1.19-2.16), low level of perceived love and support from subject's wife (OR = 2.06, 95% Cl 1.05-4.05), and restraining retaliation when hurt by coworkers (OR = 1.89, 95% Cl 1.19-3.00). This study confirms several previously reported risk factors and underlines the importance of stress, lack of social support, and coping style in the development of duodenal ulcer.

Problems and issues in family medicine psychosocial research.

The authors believe that, despite their complexity, psychosocial factors should be included with biological variables in family medicine research. To aid this process, this article reviews some problems and issues in selected areas of psychosocial research relevant to family medicine. Basic background material, dimensions, models, intra-individual, intra-familial physiological mechanisms of transmission, and factors related to stress, support and coping, are discussed. This is followed by methodological issues that include research design, psychometric properties of measures, data collection, quantitative and qualitative methods, family assessment problems and techniques, and analytic procedures. The latter includes scoring problems, global versus specific questions, and statistical analyses issues. Finally, a discussion of biological relationships and potential biological markers for psychosocial processes or variables concludes this review.

Health and illness behavior of Type A persons.

The complex and controversial relationship of type A behavior to myocardial infarction and other illnesses may be mediated through health habits and illness behavior. We hypothesized that type A persons tend to reject the sick role, delay in seeking medical care, seek convenient medical care facilities, are impatient for recovery, return to work before they have fully recovered, and are less likely to engage in positive health habits. A cross-sectional survey was conducted at a large corporation in Cleveland, Ohio. A detailed questionnaire that examined health-promoting and illness behaviors was sent to 385 managers, 54% of whom responded. Models tested using path analysis supported the hypotheses that type A persons are more likely than are type B employees to reject the sick role, delay in seeking medical care, be impatient for recovery, and return to work before a full recovery. The study findings imply that type A employees may be less likely to miss work for minor illnesses, but they may be prone to adverse outcomes from illnesses that require early care or assumption of the sick role. The hypothesis that type A persons are less likely to engage in positive health-habits behavior was not supported.