The family profile: a new self-report instrument for family assessment.

The Family Profile is a new self-report family assessment instrument that is grounded in family theory and designed following a construct validation approach to instrument design that integrated theoretical concepts with test construction and empirical analysis. Development consisted of three component phases: rational theoretical design, empirical structural analysis, and psychometric validation. The first theoretical design phase resulted in a 231-item instrument with 13 construct scales. Structural analysis data were collected from a pilot sample of 160 patients selected from 6 family practice clinics in urban, suburban, and rural locations. After revision based on item and scale analysis, a 129-item instrument was administered to a random sample of 876 patients from family practices throughout Minnesota. Responses were analyzed for item- and scale-distribution characteristics, item-scale and scale-scale correlations, correlation with social desirability, factor analysis to confirm or disconfirm the existence of the theoretical dimensions, internal consistency reliability, and test-retest reliability. This analysis reduced the instrument to 90 items from all 13 postulated constructs that cluster into 6 main factors--Family Concordance, Family Discordance, Marital Strength, Active Involvement, Religiosity, and Parental Leadership. The Family Profile is also temporally stable and free from social desirability bias. Validation (construct and criterion) and normative data studies of various populations are in progress.

Sexual dysfunction, Part II: Diagnosis, management, and prognosis.

BACKGROUND: Sexual problems are common but infrequently diagnosed. They are classified into four major categories: (1) sexual desire disorders, (2) sexual arousal disorders, (3) orgasmic disorders, and (4) sexual pain disorders. METHODS: MEDLINE files from 1966 to the present were searched using the specific sexual dysfunctions as key words along with the general key word "sexual dysfunction" to review the published literature. Additional articles came from the reference lists of dysfunction-specific reviews. RESULTS AND CONCLUSIONS: The key to diagnosis often rests on the physician's willingness to raise the issue with patients. A rational protocol can be followed to identify causative organic and psychogenic factors using the psychosexual and medical history, a comprehensive physical examination, psychological assessment instruments, laboratory tests, and special procedures. Current psychological treatment includes one or more of the following components: sensate focus exercises, cognitive-behavioral therapy, relaxation training, hypnosis and guided imagery, and group therapies. Specific techniques, such as directed self-stimulation, the stop-start and squeeze techniques, the sexological examination, systematic desensitization, and Kegel exercises, are added therapy when appropriate. Marital therapy to improve communication and resolve conflict is also part of standard therapy. Medical management can include pharmacologic agents to correct endocrine dysfunctions or to alter the progression of the sexual response. Surgical management can involve arterial revascularization, venous ligation, and penile implants. A noninvasive vacuum constriction device is also used to treat erectile disorders. The long-term prognosis of the sexual dysfunctions varies with the type of disorder and its causes. Generally good results (80 to 95 percent satisfaction) are obtained when treating vaginismus, dyspareunia, male erectile disorders, and female orgasmic dysfunctions. Long-term results are modestly successful (40 to 80 percent) when treating inhibited male orgasm and premature ejaculation. Long-term success is poorest at present for treating sexual desire disorders.

Sexual dysfunction, Part I: Classification, etiology, and pathogenesis.

BACKGROUND: The sexual dysfunctions are extremely common but are rarely recognized by primary care physicians. They represent inhibitions in the appetitive or psychophysiologic changes that characterize the complete adult sexual response and are classified into four major categories: (1) sexual desire disorders (hypoactive sexual desire, sexual aversion disorder), (2) sexual arousal disorders (female sexual arousal disorder, male erectile dysfunction), (3) orgasmic disorders (inhibited male or female orgasm, premature ejaculation), and (4) sexual pain disorders (dyspareunia, vaginismus). METHODS: Articles about the sexual dysfunctions were obtained from a search of MEDLINE files from 1966 to the present using the categories as key words, along with the general key word "sexual dysfunction." Additional articles came from the reference lists of dysfunction-specific reviews. RESULTS AND CONCLUSIONS: Cause and pathogenesis span a continuum from organic to psychogenic and most often include a mosaic of factors. Organic factors include chronic illness, pregnancy, pharmacologic agents, endocrine alterations, and a host of other medical, surgical, and traumatic factors. Psychogenic factors include an array of individual factors (e.g., depression, anxiety, fear, frustration, guilt hypochondria, intrapsychic conflict), interpersonal and relationship factors (e.g., poor communication, relationship conflict, diminished trust, fear of intimacy, poor relationship models, family system conflict), psychosexual factors (e.g., negative learning and attitudes, performance anxiety, prior sexual trauma, restrictive religiosity, intellectual defenses), and sexual enactment factors (e.g., skill and knowledge deficits, unrealistic performance expectations). Understanding the cause and pathophysiology of sexual disorders will help primary care physicians diagnose these problems accurately and manage them effectively.

The family stress and support inventory (FSSI).

The Family Stress and Support Inventory (FSSI) is a new self-report family assessment instrument that is theoretically grounded in sociological and family stress theory and designed to provide a brief, reliable, valid, quantifiable, and global assessment of the intrafamilial stress and support variables. With reference to clearly defined constructs, the respondents rate on a continuum of 1-10 the amount of stress and support that they feel from each individual family member. Scale analysis and psychometric evaluation were completed on a randomly selected sample of 382 people chosen from family practice clinics throughout Minnesota and the University of Minnesota faculty and staff. The test-retest correlations are r = .78, p = .00 for the FSSI Support scale, and r = .68, p = .00 for the FSSI Stress scale. Correlation with social desirability is negligible (r = -.01, p = ns for FSSI Support; r = .11, p = .02 for FSSI Stress). The FSSI Stress scale demonstrates moderately high concurrent validity with the Family Inventory of Life Events and Changes (FILE), another family stress measure (r = .50, p = .00), indicating that both assess similar, but not identical, family stress dimensions. The correlation between the FSSI Support scale and the Family Inventory of Resources for Management (FIRM), another measure of family resources, however, was only r = .10, p = .05, indicating that these two measures evaluate different family support dimensions. The FSSI has many potential applications in family medicine research and clinical care where the intrafamilial stress and support variables must be quantified.

Self-report family assessment instruments: an evaluative review [see comment].

Family medicine is challenged to document the impact of family systems on health and physiologic function. For this research investigators must measure family system variables with instruments that are both valid and reliable. In this context, eight self-report measures of total family functioning are reviewed and assessed according to a standardized approach to instrument design. The instruments evaluated include the Family Assessment Device, the Family Assessment Measure, the Family Adaptability and Cohesion Evaluation Scales, the Family Environment Scale, the Family Functioning Index, the Self-Report Family Inventory, the Family APGAR, and the Family Functioning Questionnaire. The analysis indicates two major problems with these instruments. First, there is disagreement on key concepts and definitions. Second, there is inconsistency in design and attention to detail in empirical analysis and psychometic evaluation. Family assessment techniques need further development and remain a fertile research field for family medicine investigation.

Interpreting office radiographs. A guide to systematic evaluation.

Office radiographs are important diagnostic tools for most family physicians, and most family physicians believe that they should be capable of interpreting 90% of these films without referral to a radiologist. Optimal use of these radiographs requires that patients are appropriately selected, that the examination is adequately conducted, and that the films are accurately interpreted. Interpretive accuracy is enhanced if radiographs are analyzed by physicians skilled in observing and interpreting them and if the images are examined in a logical, systematic manner to minimize observer bias. A systematic search pattern is proposed to facilitate family physicians' interpretations for the most common office radiographs: chest, extremities, abdomen, skull, and spine.

Indications for office radiographs.

Radiology is an essential part of the family physician's office practice. Like most diagnostic tools, radiographs can provide valuable information, but they also have the potential to be abused. One of the first tasks in ensuring optimal use of any procedure is to establish criteria for proper patient selection. This article is a review of general and specific indications for office radiographs on both symptomatic and asymptomatic patients based on published expert consensus and studies that have examined indications for radiographs using clinical criteria. For symptomatic patients, indications are discussed for the following radiographs: extremities (traumatic and nontraumatic), skull, abdomen, chest, orbits, sinuses, facial bones, and spine. Indications for asymptomatic patients are discussed with specific attention to lumbosacral spine and chest radiographs. When appropriate indications are followed, the physician can avoid the problem of overuse and its consequent radiation and economic burdens, as well as the problem of underuse with its risk of incomplete evaluation.

Designing self-report instruments for family assessment.

As family medicine research expands, more and better self-report measures for quantifying family systems variables will be required. These measures should be developed from an accepted paradigm for instrument design that includes the following. They should be: 1) grounded in a contemporary conceptual framework; 2) constructed following a rational theoretical design that includes the sequential stages of construct identification, construct definition, item generation, item editing, item formatting, and item scoring; 3) analyzed empirically at the item level for item distribution characteristics, item-scale correlation, and item-response style correlations; 4) analyzed at the scale level for scale distribution characteristics, scale-scale correlations, and scale-response style correlation; 5) revised based on editing and empirical analysis; and 6) psychometrically evaluated for reliability (eg, internal consistency, test-retest) and validity (construct related, criterion related, and content related). Normative data from various reference populations must also be obtained to provide a basis for interpreting scores. Finally, test manuals must be written to summarize test development data and provide information on administration procedures, scoring, and interpretation.

Interpreting office radiographs: a research-based curricular prototype for training family practice residents.

Radiographic film interpretation is one area of the family practice residency training curriculum that has been given little focused emphasis. Starting with a series of studies into the office practice of radiology by family physicians to define need, content, and interpretation skill level, and following a systematic curriculum design process, the authors developed a comprehensive curriculum for teaching office X-ray interpretation to family practice residents. The final curricular prototype consists of: 1) a complete set of curriculum objectives; 2) a written monograph; 3) a set of instructional X-rays; and 4) a set of evaluation films. This research-based curriculum development process may serve as a model for developing other educational components for family practice residency training.

Common problems of the oral cavity.

The oral cavity is an area of the human body that is often given only cursory surveillance by primary care physicians. In this article, I have discussed a comprehensive approach for collecting subjective and objective data from the patient that is pertinent to oral conditions. Most common and critical problems have been reviewed in detail, focusing on their definition, epidemiology, pathophysiology, clinical manifestations, diagnosis, and management. This review is intended to sensitize physicians to the need to evaluate oral complaints more completely, to diagnose them more accurately, and to treat them more successfully.

Radiology in family practice: a prospective study of 14 community practices.

This study prospectively examined x-rays obtained in the offices of 14 family physicians who read all their own office x-rays and then select those they want a radiologist to read. Each physician completed a standardized report form for 100 consecutive x-rays or for all x-rays obtained for three months, whichever came first. A total of 1,127 x-rays were evaluated. The results indicate that: 1) 86.5% of all x-rays were of three types (chest x-ray, 50.8%; upper extremity, 18.9%; lower extremity, 16.8%); 2) 85.3% of all x-rays were obtained to: a) confirm a clinical diagnosis, b) establish a diagnosis, c) screen for potential problems; 3) 84.8% of the referred x-rays were referred to a) confirm the family physician's interpretation, b) interpret equivocal findings, c) provide medicolegal support, d) improve interpretation skills; 4) the referral rate to a radiologist was 11.6%, with chest x-rays referred most frequently; 5) the same five major ICD-9-CM diagnostic categories were associated with 90.1% of all x-rays obtained and 86.5% of all x-rays referred; 6) the types of x-rays obtained in community practice and in a previously studied residency training practice were similar; 7) 55.6% of office x-rays were read as "normal;" and 8) the family physicians' discordancy rate with the radiologists on referred films was 12.5%.

The interpretation of office radiographs by family physicians.

This study prospectively compared the interpretations of family practice residents and faculty with those of radiologists on 532 office radiographs using a uniform protocol. A total of 136 family practice residents (44 first-year, 40 second-year, 52 third-year) and 42 full-time and part-time faculty participated in the study along with 30 radiologists. The mix of radiographs evaluated was as follows: 44 percent chest, 20 percent lower extremity, 6 percent head, 4 percent lumbosacral spine, 3 percent cervical-thoracic spine, and 3 percent abdomen-pelvis. Interpretation concordance rates between family physicians and radiologists, by level of training, were as follows: first-year residents 83.0 percent, second-year residents 84.4 percent, third-year residents 86.0 percent, and faculty 88.6 percent. Concordance after the resident and faculty preceptor discussed the film and provided a collaborative interpretation was 92.1 percent. This finding compares with previously reported error rates of 10 to 40 percent between experienced radiologists. Only 10.3 percent of the discordant readings (0.8 percent of all radiographs) contained significant discordancies that may have affected patient management or outcome. Had the family physicians been given the option to refer an x-ray film to the radiologist, all x-ray films containing significant discordancies would have been referred.

Radiology in family practice: a descriptive study of office practice.

This study examined all x-rays from five family practice clinics for the year 1987, recording x-ray type together with the age and sex of the patient x-rayed. A total of 4,024 x-rays was obtained from 71,192 patient visits--an x-ray utilization rate of 5.65 percent. Most office x-rays were of the chest (39.6 percent), upper extremities (21.3 percent) or lower extremities (21.0 percent). These three categories predominated for all age groups of both sexes, for all months of the year, and for all clinics studied. Males utilized x-rays much more frequently than did females (8.86 percent overall rate for males; 3.95 percent overall rate for females) at all ages except for the age group 0-10 (2.19 percent for males, 3.04 percent for females). The gender combined age group with the highest utilization rate was between 51-60 (8.39 percent) whereas the gender combined age group 0-10 had the lowest utilization rate (2.61 percent). Uniformity was demonstrated from clinic to clinic on type of x-rays obtained, frequency of x-rays by gender, and frequency of x-rays per month. A major difference, however, was noted in utilization rates between clinics. There was a two-fold difference in x-ray utilization between the clinic with the highest utilization rate and the one with the lowest. This data is useful for focusing the content of residency training and continuing medical education in radiology, for providing a content base to evaluate family physicians in radiology, and for providing a foundation upon which further investigations into office radiology can be constructed.

Radiology in family practice: experience in community practice.

This study examined the utilization and interpretation of office x-rays in community practice. Analysis of physician and practice descriptive data obtained by survey from the Minnesota Academy of Family Physicians Research Network, a representative sample of family physicians in Minnesota, leads to these conclusions: (1) Most (87.3%) of the study physicians have on-site x-ray facilities. (2) An extensive variety of x-rays is obtained in the office. (3) Most (54.2%) family physicians interpret their own x-rays and self-select those they want re-read by a radiologist; 43.8% referred all x-rays to a radiologist. (4) Of those who self-select x-rays for referral, 68.9% refer 10% or fewer films. (5) Reasons for referral are: (a) to follow an "a priori" decision, (b) to make a diagnosis when clinical findings are inconclusive, (c) to confirm the physician's own clinical diagnosis, (d) to protect from medical-legal problems, and (e) to consult because of the seriousness of the problem. The study physicians also believe that the interpretation of office x-rays is a basic skill of the family physician, that residents should be trained to interpret 90% or more of their office x-rays, and that radiologists should be used as consultants on the basis of identified need similar to the way other consultants are used. The study also showed that decision criteria for referral are based on sound clinical and quality of care issues, that liability concerns have a definite influence on referral rates for x-ray interpretation, and that a contractual reading arrangement with a radiologist and close proximity to a radiologist both tend to increase his or her use.