Biomedical subjects
M K Marvel
Publications and source records attributed to M K Marvel.
Soliciting the patient's agenda: have we improved?
CONTEXT: Previous research indicates physicians frequently choose a patient problem to explore before determining the patient's full spectrum of concerns. OBJECTIVE: To examine the extent to which experienced family physicians in various practice settings elicit the agenda of concerns patients bring to the office. DESIGN: A cross-sectional survey using linguistic analysis of a convenience sample of 264 patient-physician interviews. SETTING AND PARTICIPANTS: Primary care offices of 29 board-certified family physicians practicing in rural Washington (n = 1; 3%), semirural Colorado (n = 20; 69%), and urban settings in the United States and Canada (n = 8; 27%). Nine participants had fellowship training in communication skills and family counseling. MAIN OUTCOME MEASURES: Patient-physician verbal interactions, including physician solicitations of patient concerns, rate of completion of patient responses, length of time for patient responses, and frequency of late-arising patient concerns. RESULTS: Physicians solicited patient concerns in 199 interviews (75.4%). Patients' initial statements of concerns were completed in 74 interviews (28.0%). Physicians redirected the patient's opening statement after a mean of 23.1 seconds. Patients allowed to complete their statement of concerns used only 6 seconds more on average than those who were redirected before completion of concerns. Late-arising concerns were more common when physicians did not solicit patient concerns during the interview (34.9% vs 14.9%). Fellowship-trained physicians were more likely to solicit patient concerns and allow patients to complete their initial statement of concerns (44% vs 22%). CONCLUSIONS: Physicians often redirect patients' initial descriptions of their concerns. Once redirected, the descriptions are rarely completed. Consequences of incomplete initial descriptions include late-arising concerns and missed opportunities to gather potentially important patient data. Soliciting the patient's agenda takes little time and can improve interview efficiency and yield increased data.
Medical interviewing by exemplary family physicians.
BACKGROUND: Little is known about the extent to which models of ideal physician-patient interviews are actually practiced by physicians. This study examined physician-patient communication during medical interviews by exemplary family physicians. METHODS: We performed a cross-sectional study of verbal exchanges using 300 transcripts of office visits made to two groups of family physicians: 9 exemplars and 20 controls. The exemplars were family physicians with fellowship training in family therapy; the control group consisted of a convenience sample of board-certified family physicians with no special training in communication skills or counseling. Data were collected from June 1995 to July 1996. Physician statements were rated according to the Level of Physician Involvement model, which measures physicians' abilities to collaborate with patients and address the psychosocial concerns of patients and their families. Patient satisfaction ratings were obtained by a research assistant immediately after the visit. RESULTS: Compared with the control physicians, the exemplars showed higher levels of psychosocial involvement with patients during routine office visits. In particular, they involved patients more in the medical interview, offered more emotional support, and showed more family involvement. Despite this greater depth of involvement, the length of office visits did not differ between the two physician groups. CONCLUSIONS: Our findings show that exemplars were more involved with their patients and provided more family-oriented care than community physicians. Exemplars routinely applied a biopsychosocial approach, collaborating with patients and addressing psychosocial topics without sacrificing efficiency, while community physicians focused on biomedical issues.
Levels of physician involvement with patients and their families. A model for teaching and research.
BACKGROUND: We present an educational model that describes physician skills for addressing psychosocial concerns of patients, ranging from basic medical questions to in-depth psychotherapy. This model improves upon previously published models by integrating into one hierarchy levels of physician involvement with individual patients and levels of involvement with families. METHODS: Ten faculty family physicians were videotaped during 200 office visits. Interviews were categorized according to the model, with a 79% interrater agreement. RESULTS: Most visits involved the lower three levels of physician involvement (41%, level 1; 35.5%, level 2; and 23%, level 3). Discussion of family context occurred in a majority (58.5%) of visits, primarily when another family member was in the room and during preventive care visits. Higher levels were associated with longer visits--about 3 minutes more for each additional level. CONCLUSIONS: This investigation suggests that the levels of physician involvement model can be reliably measured. This model may be a useful tool for education and research, particularly the study of physician interview skills appropriate to family medicine.
Involvement with the psychosocial concerns of patients. Observations of practicing family physicians on a university faculty.
BACKGROUND: Physician involvement in patients' psychosocial problems, including family concerns, is a vital aspect of comprehensive medical care. This study was conducted to better understand the extent to which experienced family physicians on a university faculty address psychosocial issues and involve family members during routine outpatient office visits. METHODS: Five family physicians on a university faculty were videotaped during 200 office visits (40 per physician). Each visit was then rated on one of two five-point scales based on the extent to which psychosocial issues were addressed with individual patients and family members. Interrater reliability was 73%. RESULTS: Most interviews were focused solely on medical issues. The physicians regularly elicited the patient's opinions in a collaborative manner. Psychosocial issues (ie, family, job) were discussed in approximately 25% of the interviews, emotional reactions of patients or family members were addressed less frequently, and counseling was rarely conducted. Greater involvement in psychosocial issues was associated with longer office visits. CONCLUSION: The experienced physicians in this sample actively elicited patient's views of medical problems (ie, a "patient-centered" approach). The infrequent discussion of psychosocial concerns of the patient may be related to time limitations. Based on patients' opinions, specific attention to psychosocial issues may be most beneficial during well-child examinations and care of chronic illnesses.
Physicians' usefulness ratings of family-oriented clinical tools.
BACKGROUND: Family-oriented patient care is a cornerstone of family practice. Family practice educators have proposed various methods to help the physician to better assess and treat families. Little is known, however, of the usefulness of family-oriented clinical tools to practicing physicians. METHODS: On a mailed survey questionnaire, 595 members of the Wisconsin Academy of Family Physicians were asked to rate the usefulness of 10 family-oriented tools and indicate the frequency of use and level of training received for each item. In addition, physicians rated their current and desired level of competency for involving families in patient care. RESULTS: Two hundred ninety-nine (50%) physicians responded. Most of the tools were rated as useful but used infrequently. Identifying the effects of chemical dependency on the health of families and conducting family conferences were rated as highly useful and frequently used skills. Clinical tools rated as least useful were record keeping by family charts and folders and family function assessment by the Family APGAR: Physicians who had received training in the use of a tool rated it as more useful, except for the Family APGAR and family charts or folders. Physicians with busier practices rated some of the tools as less useful than did other physicians. Respondents indicated a desire to develop their family counseling skills. CONCLUSIONS: Most family-oriented tools were reported to be useful but used infrequently by practicing physicians. Residency programs should continue to provide training for assessing and treating families, particularly in the areas of family systems theory, self-awareness of the physician's own family background, and the effect of chemical dependency on families. Future research should target larger and more varied groups of family physicians.
Levels of family involvement by resident and attending physicians.
BACKGROUND: Family-oriented medical care is one of the basic tenets of family practice. However, little is known about the extent to which: 1) resident physicians discuss family issues during outpatient office visits and 2) attending physicians address family issues during teaching consultations. METHODS: Two hundred and fifty-one videotaped resident-patient interviews were classified according to Doherty and Baird's Levels of Family Involvement. A similar method was used to analyze the level to which family issues were included by attending physicians during 76 individual teaching consultations with residents. RESULTS: Residents asked about family issues with individual patients or spoke directly to family members about medical concerns in 41% of interviews. Planned family conferences or emotional support of family members seldom occurred. Attending physicians inquired about family information in 6% of the one-on-one teaching consultations with residents. CONCLUSIONS: The results suggest the need for increased faculty development efforts in the area of family involvement. Further applications of the Levels of Family Involvement are needed to establish norms of family orientation for residents and community family physicians.
Levels of physician involvement with psychosocial concerns of individual patients: a developmental model.
BACKGROUND: Physician involvement in patients' psychosocial concerns is seen as desirable by practicing physicians and family medicine educators. Although the effectiveness of several approaches to psychosocial problems has been demonstrated, the skills required of the physician vary widely. We present a five-level developmental model of physician skills in addressing the psychosocial concerns of individual patients. METHODS: To validate the model, 171 outpatient office visits in a residency program were videotaped and rated according to the levels. The inter-rater agreement was 88%. RESULTS: Interviews with lower levels of psychosocial involvement occurred much more frequently than interviews rated at higher levels (48%, 34%, 16%, 2%, 0%, respectively). Involvement at each higher level added approximately two minutes to the length of the visit. The development of higher levels of physician involvement between the first and third year of residency training was not found in this sample. CONCLUSIONS: These results support the validity of the five-level sequence regarding the depth of physician involvement. Because the hierarchy can be used to reliably assess the degree of physician involvement with the psychosocial concerns of individual patients, the model offers potential applications for resident education and further research on the physician-patient relationship.
A school-based intervention to increase the use of bicycle helmets.
Four family practice resident physicians provided a school-based educational intervention designed to increase the use of bicycle helmets by elementary school children in three of six public schools and to produce more favorable parental attitudes toward bicycle helmets. The effect of the one-week intervention was assessed by two parent surveys and direct observation of children riding bicycles to school. Results indicate that 60 helmets were purchased. Parents reported a change in barriers to helmet purchase, an increase in helmet ownership (13% to 27%), but observed helmet use did not increase. Both helmet ownership and use were reported to be more frequent among families with higher income and educational levels.
Attempting the improbable: offering colorectal cancer screening to all appropriate patients.
Screening tests, to be most effective, must be offered to all eligible patients. The goal of this study was to increase patient compliance with screening flexible sigmoidoscopy and fecal occult blood testing by offering these tests to all eligible patients over age 50 during office visits. During a twelve-week period, 546 patients were seen by 18 family practice resident and faculty physicians who had been randomly assigned to two intervention groups and one control group. During all visits with patients in the intervention groups, reminders were used to prompt physicians to offer the two screening tests. Patients in one of the groups also received a recall letter two weeks after the visit. The screening tests were offered to 58% of the eligible patients. Significantly more patients in the intervention groups completed the sigmoidoscopy (29% vs 2%) and fecal occult blood testing (56% vs 17%) compared with the control group patients.
Single-subject experimental designs: a practical research alternative for practicing physicians.
Single-subject research designs offer a viable alternative to the more customary group-comparison designs. The flexibility and practicality of these designs make them particularly well suited for practicing family physicians interested in testing their clinical hunches. Three designs are described that are feasible in a practice setting: ABAB (reversal), multiple-baseline, and the alternating treatment design. Either visual inspection or statistical approaches can be used to evaluate these designs. By being aware of their limitations and by following simple practical steps, the practicing physician can use these designs to improve care of individual patients while simultaneously contributing to our general knowledge.
Acupressure wrist bands to relieve nausea and vomiting in hospice patients: do they work?
This study assessed the effects of acupressure wrist bands on the nausea and vomiting of terminally ill patients. Using a single subject experimental design, six hospice patients were exposed to three conditions: An acupressure wrist band; A placebo wrist band; A no wrist band condition. Patients and their caregivers rated nausea and vomiting during the treatment. Despite some difficulty obtaining complete data, the results of this preliminary test indicate that acupressure wrist bands were not effective in reducing nausea and vomiting in this small sample of hospice patients.
A taxonomy of clinical research methods: comparisons of family practice and general medical journals.
Although an understanding of research methodology has been identified as an important skill for family practice researchers, the available literature contains confusing terminology and lacks agreement about research design classifications. A multidimensional taxonomy is presented to clarify and simplify the understanding of research designs, data collection methods, and research populations for family practice researchers. The taxonomy was used to classify 103 articles from five medical journals. Compared with general medical journals, reports in family practice journals used similar research designs but were more likely to rely on self-report data and to draw subjects from outpatient populations.
Improving clinical teaching skills using the parallel process model.
Despite a variety of efforts to develop the clinical teaching skills of family practice faculty, objective and reliable evidence of improvement has been lacking. In this study, family practice faculty physicians were videotaped during consultations with residents. Following a brief intervention, specific teaching skills increased, as indicated by follow-up videotapes and resident ratings. In particular, faculty physicians were more likely to verbally reinforce residents' efforts following the intervention. Analysis of 150 videotaped consultations revealed that several teaching behaviors remained at low rates, such as discussion of family issues. These results, when examined from the perspective of the "parallel process," suggest that faculty frequently do not model the interpersonal behaviors expected of residents during patient interviews.
Integrating family and culture into medicine: a family systems block rotation.
BACKGROUND: Family-oriented care and sociocultural awareness are core competency objectives in behavioral science education. Nevertheless, teaching "family" and "culture" in ways that are meaningful and useful to residents can be a challenging task for family medicine educators. METHODS: We describe a block rotation that integrates family systems theory, family-oriented skills, and sociocultural awareness into residency education. Several objectives and teaching methods are presented in detail. RESULTS: Resident evaluations completed one year after graduation indicated that these skills were useful in practice. All respondents recommended continuation of the block rotation in the curriculum. CONCLUSION: The success of the rotation is due to a highly interactive small-group format, an emphasis on practical skills, and a multidisciplinary teaching approach. Advanced scheduling of faculty is necessary to ensure their uninterrupted participation in the rotation.
Integration of mental health and medical records: practices and opinions of behavioral scientists.
BACKGROUND AND OBJECTIVES: This study provides information from a national sample of behavioral scientists about their practices and opinions about placement of mental health notes in the general medical record. METHODS: Using a mailed survey, behavioral scientists in US family practice residencies responded to questions about the location of mental health notes, the rationale for placement of notes, and opinions about integration of mental health notes into general medical records. RESULTS: The majority (71.8%) of behavioral scientists record mental health notes in the main body of the patient's medical chart, integrated with physician notes. Most respondents favor an integrated record to increase collaboration with medical providers. A variety of methods are used to minimize the chance of violating patient confidentiality. CONCLUSIONS: Although a majority of behavioral scientists integrate mental health notes in the medical chart and favor the practice of doing so, there is no consensus about this practice as reflected by divergent views and record-keeping methods.