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Am Fam Physician. 1998;57(6):1371-1372

A Formal Optimal Care Program for Patients with Diabetes Improves Treatment

(25th Anniversary Annual Meeting of the North American Primary Care Research Group) The development of an optimal care pathway for the management of patients with type 2 (non–insulin-dependent) diabetes provides a framework for the delivery of quality, cost-effective health care for many ambulatory patients. In a university-based family practice center and family residency training program, a team of seven health care professionals from five disciplines led the development of the care pathway. Primary goals were to improve medical education and to improve the quality of patient care. The working group was expanded to include 12 other members who met over a six-month period to prepare the program. The four components of the optimal care pathway were (1) a care pathway form, (2) a patient education flow sheet, (3) a pocket-size guidebook with additional detail and instructions, and (4) medication algorithms. The investigators emphasize that collaboration from the multidisciplinary group is necessary to develop and implement this program.—annette peery, r.n., m.s.n., et al., East Carolina University School of Medicine, Greenville, N.C.

Study Reveals Barriers to Health Care for Victims of Domestic Violence

(North American Primary Care Research Group) Because providing health care for persons who have been or currently are in abusive situations is complex, new systems of communication are needed to help lessen the barriers to providing health care and support for domestic violence victims, according to a survey conducted to identify these barriers and examine the possible solutions. A professional facilitator led discussions in each of seven focus groups with four to seven participants in each group (two groups of domestic violence network personnel, one of nurses, one of nurse practitioners, one of physicians and two of survivors of domestic violence). The health care professionals believed that the barriers to managing people in abusive situations are (1) lack of time, (2) lack of ancillary support, (3) need for confidentiality and (4) reluctance on the part of of abuse victims to seek care. Network personnel felt that the barriers preventing health care professionals from recognizing and discussing abuse were (1) lack of time, (2) lack of training and (3) stereotyping of abuse victims to specific socioeconomic classes. The survivors of abuse believed that the barriers include the following: (1) lack of interest or time by physicians, (2) physicians' lack of recognition of the victim's symptoms of emotional distress and depression as signs of abuse, and (3) victims' fear of blame for the abuse.—luann rolley, et al., University of Vermont, Burlington.

Family Physicians Encounter A Variety of Mental Health Problems

(North American Primary Care Research Group) Family physicians provide psychotherapy and prescribe psychotropic medications for a wide range of mental disorders in their clinical practice. This was the conclusion of a study that examined the types of mental disorders family physicians see and the kinds of treatment they provide to their patients. Graduates of a family medicine residency program were surveyed regarding their treatment of mental health problems. One hundred fifty-four physicians responded to the survey. The most frequently encountered mental health problems were reported to be the following: situational distress (77 percent of physicians), general anxiety disorders (58 percent), major depression (54 percent) and alcohol abuse/dependence (54 percent). The percentages of physicians who reported treating the mental health problems follow: general anxiety disorders (62 percent), panic attacks/disorders (58 percent), situational distress (54 percent), major depression (52 percent), alcohol abuse/dependence (44 percent), dysthymia (41 percent) and somatization disorders (38 percent). In addition, 91 percent of the physicians prescribed psychotropic medication and 66 percent provided psychotherapy to their patients with mental health problems.—bruce r. deforge, ph.d., et al., University of Maryland Family Practice Residency Program, Baltimore.

Test Measures Changes In Patients Receiving Antidepressant Therapy

(North American Primary Care Research Group) A personality assessment inventory (PAI) used in patients seen in a family medicine clinic who were receiving selective serotonin reuptake inhibitors showed that the patients experienced changes in both symptoms of depression and other psychopathology. The PAI is a self-report objective personality inventory designed to measure a broad range of psychopathology. A total of 28 patients were enrolled in the study and completed the first test. Fifteen patients completed the second test. The patients completing both tests showed changes in scales measuring depression, as well as other symptoms. Although PAIs are cumbersome because they are lengthy and difficult to interpret, the investigators believe that they offer a large amount of information relevant to the study of behavioral effects of antidepressant medications.—marcia smith, ph.d., et al., St. Anthony Family Practice Residency Program, Denver.

Family Physicians Need to Educate Patients About Use of Antibiotics

(10th Annual Conference on Patient Education) Most family physicians have become aware of the need to limit antibiotic use and understand the role of outpatient antibiotic use in the development of antibiotic resistance. In the past, oral antibiotics were often prescribed inappropriately. One reason is that patients frequently ask for antibiotics. Education is at the heart of any changes geared toward limiting outpatient antibiotic use. Physicians need to identify strategies for improving patient satisfaction when the desired therapy (e.g., antibiotics) is not considered appropriate. A few moments spent on patient education will help familiarize patients with the risks of overusing antibiotics. Assurance of close follow-up of the illness may make the patient more comfortable with the selected treatment. Consistent policies among the physicians in a practice on the use of antibiotics will communicate to the patients in that practice a reliable standard of care.—caroline wellbery, m.d., Georgetown University School of Medicine, Washington, D.C.

End-of-Life Counseling Should Focus on Needs and Fears of the Patient

(Conference on Patient Education) Physicians who initiate end-of-life discussions with their critically ill patients will better understand the needs and fears of their patients and be able to work as a team with the patient and family to create a dying experience that reflects these needs, according to a presentation of a patient-centered approach to end-of-life discussions. Before physicians embark on end-of-life discussions, it is important that they clarify their own values regarding the end of life. Physicians can then separate their personal values from those of the patient. Physicians should include questions about dying during routine visits of any patient with chronic illness and all geriatric patients, regardless of their health status. Continuing to revisit this issue is important, because patients may have new concerns. Psychosocial assessment of the patient should be ongoing during these discussions. It is also important for the physician to understand the patient's family structure, core values and spiritual beliefs. The presenters believe that the family physician is in a unique position to address the patient's fears and concerns that may not be expressed to anyone else.—penny thron-weber, m.d., and dwight duncan, psy.d., St. Anthony Family Medicine Residency Program, Denver.

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