Preparing Family Physicians to Care for Underserved Populations: A Historical Perspective.

BACKGROUND: Family physicians have been involved in the care of rural and urban underserved populations since the founding of the specialty. In the early 1970s family medicine training programs specifically focused on training residents to work with the underserved were established in both urban and rural settings. Key to the success of these programs has been a specific focus on improving access to care, understanding and eliminating health disparities, cultural competency and behavioral science training that recognizes the challenges often faced by patients and families living in poor rural and urban areas of the country. In keeping with a focus on the underserved, several urban underserved residencies also became national models for the provision of primary care to patients and families affected by HIV/AIDS. Family medicine training programs focused on the underserved have resulted in the development of a cohort of family physicians who care for those most in need in the United States. Despite these achievements, persistent challenges remain in providing adequate access to care for many living in rural and inner city settings. New strategies will need to be developed by family medicine programs and others to better meet these challenges.

Adherence in single-parent households in a long-term asthma clinical trial.

Adherence of participants in a long-term clinical trial is necessary to assure validity of findings. This article examines adherence differences between single-parent and two-parent families in the Childhood Asthma Management Program (CAMP). Adherence was defined as the percentage of completed daily diary cards and scheduled study visits during the course of the trial. Logistic regression and ordinal logistic regression analyses were used. Children from single-parent families had a lower percentage of completed diary cards (72% vs. 84%) than two-parent families. Single-parent families were also more likely to reschedule visits (62% vs. 45%) and miss more clinic visits (23% vs. 17%) than two-parent families. Suggestions are given for study coordinators to assist participants in completing a long-term clinical trial. Many suggestions may be adapted for nurses in inpatient or outpatient settings for assisting parents of patients with chronic diseases.

Effectiveness of a time-limited cognitive behavior therapy type intervention among primary care patients with medically unexplained symptoms.

PURPOSE: Patients seeking care for medically unexplained physical symptoms pose a major challenge at primary care sites, and there are very few well-accepted and properly evaluated interventions to manage such patients. METHODS: We tested the effectiveness of a cognitive behavior therapy (CBT)-type intervention delivered in primary care for patients with medically unexplained physical symptoms. Patients were randomly assigned to receive either the intervention plus a consultation letter or usual clinical care plus a consultation letter. Physical and psychiatric symptoms were assessed at baseline, at the end of treatment, and at a 6-month follow-up. All treatments and assessments took place at the same primary care clinic where patients sought care. RESULTS: A significantly greater proportion of patients in the intervention group had physical symptoms rated by clinicians as "very much improved" or "much improved" compared with those in the usual care group (60% vs 25.8%; odds ratio = 4.1; 95% confidence interval, 1.9-8.8; P<.001). The intervention's effect on unexplained physical symptoms was greatest at treatment completion, led to relief of symptoms in more than one-half of the patients, and persisted months after the intervention, although its effectiveness gradually diminished. The intervention also led to significant improvements in patient-reported levels of physical symptoms, patient-rated severity of physical symptoms, and clinician-rated depression, but these effects were no longer noticeable at follow-up. CONCLUSIONS: This time-limited, CBT-type intervention significantly ameliorated unexplained physical complaints of patients seen in primary care and offers an alternative for managing these common and problematic complaints in primary care settings.

Symptom perception in childhood asthma: the role of anxiety and asthma severity.

This study tested the relationship of anxiety and asthma severity to symptom perception. Eighty-six children diagnosed with mild or moderate asthma had symptom perception and pulmonary function measured throughout methacholine challenge (to induce bronchoconstriction). Higher trait anxiety was associated with heightened symptom perception (controlling for pulmonary function) at baseline. Greater asthma severity was associated with blunted symptom perception (controlling for pulmonary function) at the end of methacholine challenge and with a slower rate of increase in symptom perception across methacholine challenge. These results suggest that anxiety plays a role when children's symptoms are mild, whereas medical variables such as severity play a role in perception of changes in asthma symptomatology as bronchoconstriction worsens.

The Future of Family Medicine: a collaborative project of the family medicine community.

BACKGROUND: Recognizing fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. METHODS: A national research study was conducted by independent research firms. Interviews and focus groups identified key issues for diverse constituencies, including patients, payers, residents, students, family physicians, and other clinicians. Subsequently, interviews were conducted with nationally representative samples of 9 key constituencies. Based in part on these data, 5 task forces addressed key issues to meet the project goal. A Project Leadership Committee synthesized the task force reports into the report presented here. RESULTS: The project identified core values, a New Model of practice, and a process for development, research, education, partnership, and change with great potential to transform the ability of family medicine to improve the health and health care of the nation. The proposed New Model of practice has the following characteristics: a patient-centered team approach; elimination of barriers to access; advanced information systems, including an electronic health record; redesigned, more functional offices; a focus on quality and outcomes; and enhanced practice finance. A unified communications strategy will be developed to promote the New Model of family medicine to multiple audiences. The study concluded that the discipline needs to oversee the training of family physicians who are committed to excellence, steeped in the core values of the discipline, competent to provide family medicine's basket of services within the New Model, and capable of adapting to varying patient needs and changing care technologies. Family medicine education must continue to include training in maternity care, the care of hospitalized patients, community and population health, and culturally effective and proficient care. A comprehensive lifelong learning program for each family physician will support continuous personal, professional, and clinical practice assessment and improvement. Ultimately, systemwide changes will be needed to ensure high-quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home, promoting the use and reporting of quality measures to improve performance and service, advocating that every American have health care coverage for basic services and protection against extraordinary health care costs, advancing research that supports the clinical decision making of family physicians and other primary care clinicians, and developing reimbursement models to sustain family medicine and primary care practices. CONCLUSIONS: The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans.

Holistic healing for women with breast cancer through a mind, body, and spirit self-empowerment program.

This article reports results of an integrated mind-body-spirit self-empowerment program for breast cancer survivors. Fifty-one women at various stages of breast cancer completed a series of eclectic lessons offered in a support group format. The program followed an integrated and cumulative lesson plan that progressively and systematically introduced multiple strategies for creating a balance among mental, emotional, spiritual, and physical health. The program's goals were to enable participants to experience a reduction in distress, improve perceived quality of life, reach a deeper sense of meaning and purpose in life, and experience a greater sense of perceived wellness. Self-assessments were obtained on four well-documented measures relating to both pre- and postprogram participation. Differences in pre- and postscores showed statistically significant improvement and large estimated effect sizes on all four measures. Participants' written comments provide examples of the scope and benefits of the program.