Letters to the Editor - November 1, 2001 - American Family Physician

Letters to the Editor

FRAMES Method Helps Assess Patients' Readiness to Change

TO THE EDITOR: I read with great interest the article by Dr. Rustin, "Assessing Nicotine Dependence."¹ Dr. Rustin provides an excellent introduction to the concept of "motivational interviewing." The CAGE questionnaire and other tools are used to determine the intensity of a patient's nicotine dependence. The patient's readiness to change the dependent behavior also is evaluated during the session. This thorough evaluation could lead to a potentially lengthy encounter. I agree with the statement concerning the time constraints of average office visits for a family practice physician.²

Once a patient's level of motivation for change is evaluated using the CAGE questionnaire, Miller and Rollnick address time constraints through use of the mnemonic FRAMES.^3,4 This method permits the therapeutic process to continue with elements intuitively familiar to physicians, allowing an effective and brief patient encounter. FRAMES begins with Feedback, which involves discussing assessment results with the patient and may include such items as laboratory results or the modified Fagerstrom test mentioned in the article. Also included in this brief encounter is an emphasis on personal Responsibility, and Advice clearly stating the initial steps for behavioral change. Similarly, Menu and Empathy denote, respectively, a list of options and vocalized understanding of the patient's stated and unstated responses. Finally, the therapist, by instilling a sense of Self-efficacy within the patient, can promote the optimism needed to achieve success in this endeavor.⁵ The FRAMES approach is useful for brief or single-visit interventions dealing with substance abuse. Additionally, this approach is applicable to the behavioral changes needed by patients for a wide variety of medical conditions commonly encountered by family physicians.⁶

Assessing nicotine dependence or other health-associated behaviors is an important first step for evaluating a patient's readiness to change. The reality for busy health professionals necessitates use of existing skills (FRAMES method) with effective assessment strategies (tools from the article) to maximize patient motivation for change and selection of the optimum treatment regimen.

ROBYN DANIELL, M.D.
Department of Family Medicine
Morehouse School of Medicine
Atlanta, GA 30331-2099

REFERENCES

Rustin TA. Assessing nicotine dependence. Am Fam Physician 2000;62:579-84,591-2.

Jorenby DE, Fiore MC. The Agency for Healthcare Policy and Research smoking cessation clinical practice guideline: basics and beyond. Prim Care 1999;26:513-28.

Miller WR, Rollnick S. Motivational interviewing: preparing people to change addictive behavior. New York: Guilford Press, 1991:30-5.

Miller WR. Motivational interviewing: research, practice, and puzzles. Addict Behav 1996;21:835-42.

Frank JD, Frank JB. Persuasion and healing: a comparative study of psychotherapy. 3d ed. Baltimore: Johns Hopkins University Press, 1991:132-53.

Sippel JM, Osborne ML, Bjornson W, Goldberg B, Buist AS. Smoking cessation in primary care clinics. J Gen Intern Med 1999;14:670-6.

Vaginal Examination Using the Sims Position

I would like to comment on Dr. Bachmann's editorial¹ about the importance of obtaining a sexual history. Dr. Bachmann discusses the difficulty, at times, in performing a proper vaginal examination with the patient in the usual lithotomy position, mainly because of patient resistance. There is another examination position that is rarely used in the United States--the Sims position, using a Sims speculum (although described and invented by the American surgeon, Dr. Marion Sims, it is used mainly overseas).

I was taught this technique while an American medical student in Australia during the early 1950s. It is especially useful for noting cystocele, rectocele and uterine prolapse. This technique is illustrated in Pye's Surgical Handicraft.² The patient lies in the Sims position, the Sims speculum is introduced easily laterally and the vagina falls open--the entire anterior wall and both lateral walls are fully revealed. Rotating the speculum reveals the posterior wall, together with the lateral walls again. Bartholin's gland is easily palpated, and cervical smears are easily obtained.

The advantages of this technique are (1) less embarrassment for the patient, (2) better visualization of all of the vagina, (3) better visualization of the cervix for biopsy or smears, (4) easily palpated glands and (5) visualization of cystocele, rectocele and uterine prolapse and degree thereof.

I truly wish this method would be taught and reintroduced into the country of its origin. Examination in the lithotomy position with the patient's feet in stirrups seems to be designed for the advantage of the examiner with little consideration for the patient.

WALTER SCHNUR, M.D.
8746 Cavalier Drive
Cincinnati, OH 45231-5041

REFERENCES

Bachmann G. The importance of obtaining a sexual history [Editorial]. Am Fam Physician 2000;62: 52-60.

Pye W, Bailey H. In: Bailey H, ed. Surgical handicraft: a manual of surgical manipulations, minor surgery, and other matters connected with the work of surgical dressers, house surgeons and practitioners. 16th ed. Bristol: John Wright & Sons, 1950:374-7.

IN REPLY: I concur with Dr. Schnur's plea for considering other positions to fully evaluate the pelvis of women; however, like all techniques in medicine, the examiner must be familiar and comfortable in examining the patient in the position he or she uses. Good mentoring for performing the gynecologic examination in different pelvic positions is usually lacking in the United States.

Regardless of the examination position, however, it is critical that the pelvic examination remains an integral part of the general health check-up for every woman. The examiner must be knowledgeable not only in the technical aspects of how to perform a pelvic examination but also must be aware of the distress and fear the examination often evokes in the patient and be responsive to this. As an obstetrics and gynecology resident during the 1970s, I read an excellent piece on the pelvic examination that serves as a great reminder of how sensitive we as physicians must be when performing a pelvic examination.¹

GLORIA BACHMANN, M.D.
UMDNJ--Robert Wood Johnson Medical School
125 Paterson St.
New Brunswick, NJ 08901

REFERENCE

Magee J. The pelvic examination: a view from the other end of the table. Ann Intern Med 1975; 83:563-4.

Corrections

Question 12 of the "Clinical Quiz" (May 15, 2000, page 2963), which referred to the article "The Painful Shoulder: Part I. Clinical Evaluation," was poorly worded. The correctly worded question follows; the correct answer is D.

Q12. Which major joint is most commonly dislocated?

A. Elbow.

B. Finger.

C. Toe.

D. Shoulder.

E. Hip.

The article "Subclinical Hypothyroidism: Deciding When to Treat" (February 15, 1998, page 776) contained an error in the text of a color block at the top of page 780. The correct dosage of levothyroxine is 25 to 50 mcg.

Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax:913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Please submit a word count. Letters submitted for publication in AFP must not be submitted to any other publication. Possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors may edit letters to meet style and space requirements.

The editors of AFP welcome input concerning topics of current medical interest and feedback in response to articles and other material published in AFP. Send letters to Jay Siwek, M.D., Editor, American Family Physician, 11400 Tomahawk Creek Parkway, Leawood, KS 66211-2672; fax: 913-906-6080; e-mail: afplet@aafp.org. Please include your complete address, telephone number and fax number. Letters should be double-spaced, fewer than 500 words and limited to one table or figure and six references. Letters submitted for publication in AFP must not be submitted to any other publication. Letters pertaining to AFP subject matter must be received within two months of publication. Any financial associations or other possible conflicts of interest must be disclosed at time of submission. Submission of a letter constitutes transfer of copyright to the American Academy of Family Physicians. The editors reserve the right to edit correspondence to meet style and space requirements.

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