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Doctor, boss, or both?
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Continuity of care: its importance in maintaining a teaching family practice.
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A comparison of rapid enzyme immunoassay tests for the detection of Chlamydia trachomatis cervical infections.
Two rapid enzyme immunoassay test kits were compared with culture for the detection of Chlamydia trachomatis endocervical infections. Endocervical samples for C trachomatis culture and the two enzyme immunoassay tests were evaluated from 502 county health department and Planned Parenthood patients. The prevalence of infection in this population was 12%. Sensitivity and specificity of the Abbott TestPack Chlamydia were 51.7% and 99.5%, respectively, and of the Kodak Surecell Chlamydia were 76.7% and 98.6%, respectively. The positive and negative predictive values for TestPack were 93.9% and 93.8%, and for Surecell were 88.5% and 96.9%, respectively. Additionally, an in vitro investigation was used to evaluate whether typical office staff (physicians, nurses, medical technicians, receptionists, and radiology technicians) were able to perform competently the tests in each kit. Office personnel tested 12 dilutions of a C trachomatis stock sample or negative control sample as unknowns for each kit in the in vitro investigation. There were no differences among office staff in performance when compared for each test kit. Selective use of these enzyme immunoassay tests for high-risk patients in a family practice population that has a high prevalence of patients with C trachomatis infection may be helpful when rapid test results are required and cultures are not feasible. After appropriate training, most physician office personnel were equally able to perform the enzyme immunoassay tests evaluated.
The first phone call.
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The rapid diagnosis of urinary tract infection: a side-room method.
A controlled trial of a rapid method for microscopic examination of the urine for organisms is reported. The method achieved results as accurate as those of semi-quantitative culture, at minimal cost. It is easy enough to be learned by medically untrained staff, and results are available within 10 minutes. This rapid availability of results makes it possible to prescribe more appropriately at the initial consultation.
[Reception in the Dental office].
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Reducing stress among practice staff.
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A manual system for patients' accounting records.
A medical practitioner's formalised education and practical training prior to private practice does not usually include methodology in keeping patients' accounting records. This article is directed at assisting practitioners to implement a suitable system, as well as to provide standards against which they can assess their current procedures.
A training program to improve domestic violence identification and management in primary care: preliminary results.
Domestic violence as encountered in day-to-day practice is greatly underidentified. It is estimated that only 3% of cases are presently being identified, and practitioners are uncertain of what to do if a case is discovered. In this paper, a training program to improve identification and management of domestic violence (DV) in primary care and the providers' responses to the program are described. A multimodal training program was undertaken to demonstrate and practice the incorporation of didactic content into practice for the health care teams. Two medical centers from a large staff-model HMO were chosen at random from five volunteering for training. The entire adult health care medical center teams, including physicians, physician assistants, RNs, LPNs, medical assistants, and receptionists, were the recipients of the training. Assessment of provider valuation of the components of the training program was performed by administering a standardized 5-point Likert-scaled questionnaire 9 months after the training. This time interval was chosen because we were interested in lasting program effects. Core didactic content, such as the epidemiology of DV, identification and management of victims and batterers, and legal issues, was highly rated. Delivery of the content through role-playing, start-stop videos and presentations by former victims received lesser but solid support. Follow-up assessment 9 months post training demonstrates solid support for many components of the program: highest for specific information content areas, but strong for techniques and processes. The training program appears to be a promising method to improve provider skills in DV management.
Repeat prescribing via the receptionist in a group practice.
As concern has been expressed about danger to patients, a survey about repeat prescribing via the receptionist was carried out in a group practice.About one quarter of the prescriptions in the study period were ;receptionist repeats' and these were compared with a group of repeat prescriptions obtained in the course of consultation. The receptionist repeat group contained a higher proportion of the over 65s, and relatively more men than women, though the consultation repeats and the group as a whole, were heavily biased towards women. Hypnotics and drugs to relax bronchial spasm were found more commonly among the ;receptionist repeats.'This group of patients tended to have been taking their medication for a significantly longer period than their consultation fellows, often for more than five years. Although categorised as ;receptionist repeats,' two thirds of these patients were seen by a doctor more often than six monthly. No direct evidence of any serious danger or disadvantage to the patients was found.
Facilitating care of patients with HIV infection by hospital and primary care teams.
To complement the role of primary care teams working with patients with HIV disease and AIDS within greater London and to ease the load on the special hospital units a home support team was developed. It comprises six specialist nurses, a general practitioner trained medical officer, and a receptionist and is funded from regional and district sources and charities. A nurse is available for out of hours and emergency weekend calls, with support from the patient's general practitioner or the attached medical officer. During the first 18 months 249 patients were seen; the mean duration of care was five months. Nearly a third (18/50, 30%) of patients who were terminally ill died at home. The team's activities included practical nursing care, emotional support for carers and patients, and advice and guidance to primary care teams. Problems in providing care in patients' homes included issues relating to confidentiality and 24 hour cover. With the increasing incidence of HIV infection the home support team may be a useful model for care of large numbers of patients with symptomatic HIV disease, especially in large urban areas.
The Larimer County Children's Clinic. A public-private partnership to provide medical care to indigent children.
OBJECTIVE: To describe a unique collaboration between private and public entities to provide comprehensive health care to medically indigent children in rural Larimer County, Colo. SETTING: The Children's Clinic, Fort Collins, Colo. STUDY PARTICIPANTS: Uninsured children and those eligible for Medicaid, living in families with incomes below 150% of the federal poverty level. SELECTION PROCEDURES: Eligible patients have been enrolled in the Children's Clinic on a first-come, first-served basis. INTERVENTIONS: A community collaboration involving an interactive system with the Children's Clinic staff, the Larimer County Department of Health and Environment, private primary care and subspecialty physicians, ancillary health providers, and the family practice residency program at Poudre Valley Hospital, Fort Collins. Funding for this endeavor has been composed of city and county funds, public and private grants, community business support, and local fund-raising efforts, as well as Medicaid reimbursements. MEASUREMENTS/MAIN RESULTS: Since 1989, comprehensive pediatric care has been provided to a growing number of eligible children. At present, 3619 children, aged birth to 18 years, from 2230 families are being served. From this population, there were 8945 office visits to the Children's Clinic, 1392 patient contacts by the clinic social workers, 1287 visits to the Larimer County Department of Health and Environment for well-child care, 543 referrals to subspecialists and other community health care providers, and 615 after-hours visits to the Poudre Valley Hospital emergency department between July 1, 1992, and June 30, 1993. The clinic's professional staff consists of 2 1/4 full-time pediatric care providers, one nurse, one medical social worker, one receptionist, and one administrator, with an expenditure of $356,471. CONCLUSIONS: The Children's Clinic collaboration has provided comprehensive pediatric health care to a population that previously received only fragmented care. The next step is to assess the impact of this program on the frequency of emergency department visits for these patients.
Increasing patient participation using an extended consultation: an inner city study.
An inner city practice in Birmingham has developed a new style of extended consultation to increase patient participation in primary care, based on previous initiatives in the practice, in particular allowing patients access to medical records, adopting an open reception style, and including consultations with a nurse practitioner. In a three stage consultation lasting approximately 30 minutes patients were offered a session with a receptionist for assisted access to medical records, a session of 15-20 minutes with a doctor or nurse and a self help session with a receptionist. This extended consultation was welcomed by patients, who showed a marked degree of participation, and it also increased the satisfaction and cooperation of project staff. This type of consultation provides a model for increasing patient participation in general practice.
The primary-care nurse's dilemmas: a study of knowledge use and need during telephone consultations.
In Sweden (population 8 million) there are 20 million calls every year to receptionist nurses at health-care centres. The aim of this study was, first, to develop a general description of these telephone consultations in terms of the decision-making process and interpersonal communication. Second, the dilemmas that receptionist nurses encounter were to be recorded and analysed. A two-level video method was used. At the first level, a video recording of the consultation was used to draw a 'consultation map'. At the second level, the receptionist nurses reviewed and commented on the video-recording using a 'freeze frame' technique for stimulated recall and the comments were categorized. Analysis of the consultation maps showed that the receptionist nurses focused mainly on tasks related to medical diagnosis and management strategy, with less time spent on the patient's concerns, ideas and expectations. Analysis of the dilemmas showed that medical dilemmas were the most frequent, occurring in two consultations out of three. Dilemmas in the area of interpersonal communication frequently concerned distrust, either in what the patient presented, or in what the patient was said to have understood. The conclusions are that the receptionist nurses were oriented towards medical management, and that they employed an informing rather than counselling strategy. Measures must be considered to support the receptionist nurses in the medical decision-making process. Action research is suggested to apply these results in the development of the work-role of the receptionist nurse.
Trainee interns in general practices.
AIM: To determine the impact of trainee interns (sixth year medical students) on general practices involved in medical student teaching. METHOD: Postal questionnaires were sent to general practitioners, nurses and receptionists in each of 30 general practices throughout New Zealand. Questionnaires were also sent to patients in practices where a trainee intern was present during the study period. RESULTS: Nearly all of the general practitioners, receptionists and nurses found advantages in having trainee interns. Advantages included enjoyment of teaching and personal satisfaction from student involvement in the practice. Two thirds felt that the advantages would increase if the attachment duration was extended. General practitioners reported an increased level of stress and decrease in productivity, with greater hours at work per week. Remuneration was considered inadequate by a third of the general practitioners. Patients found trainee intern involvement advantageous, with improvement in quality of both care and communication. Disadvantages included longer waiting time and longer appointment time. Younger patients were more likely to find disadvantages than older patients. CONCLUSION: Trainee interns in general practices can have a beneficial impact on the quality of primary care. There are disadvantages for health care professionals and patients, and appropriate compensation (in money or time) is important for community undergraduate medical education to continue to be acceptable.
Academic group practice. The physicians' view.
In order to evaluate physician response to the reorganization of a traditional medical clinic into a group practice model, a randomized controlled trial was conducted using equivalent groups of patients and physicians. The group practice model, unlike the traditional clinic, provided decentralized registration, 5 days/week clinic coverage, and night/weekend phone coverage. Residents worked in small groups with an attending physician, nurse practitioner, staff nurse, and receptionist. A panel of 50 medical residents was interviewed prior to the reorganization and 1 year later. Residents in the experimental groups perceived improvements in the ancillary staff, placed a higher value on informal discussion of patient management problems, and were more satisfied with the outpatient experience. Moreover, residents in the group practices were more likely to voluntarily schedule additional clinic sessions to accommodate their patients. No change was noted in their career choices. We conclude that reorganization of a traditional medical clinic into a group practice model can result in increased physician satisfaction although it may not have a major impact on long-term career goals.
Drug abusers on the job.
Drug abusers in the working population range from the functional to the dysfunctional. Functional drug-abusing employees may work as productive members of a company for years without incident or detection. Cases have been documented of long-term heroin addicts with stable 10- and 20-year work histories., Studies of drug addicts in treatment with known work histories reveal that such persons can, and do, hold a broad range of jobs in the work force. In a study by Levy of 95 former addicts with histories of simultaneous employment and undetected drug abuse (including on-the-job use by 91 of the 95 addicts), the following occupations were found: bank teller; mail clerk; secretary; delivery man; stock clerk; college registrar; typist; baker; nurses aide; medical supply clerk; messenger; pharmacy clerk; receptionist; teletype operator; men's clothing salesman; truck driver; busboy; telephone installer; roofer; clothing designer; assembly line worker; waitress; auto mechanic; security officer; postal worker; credit collector; plant manager; and rigger. Reports from CODAP, a Federal statistical system covering drug treatment programs, indicate that about 20% of opiate users admitted to treatment were employed full time at the time of admission. Caplovitz found that the stable worker-addict is more similar in basic characteristics to other workers than to nonworking addicts.