Abstract: The diagnosis of patients presenting with memory or attentional deficits characteristic of dementia is a growing problem. Dementia may be symptomatic of a range of reversible medical and psychiatric conditions which appear to be indistinguishable from primary neuronal degeneration of the Alzheimer's type. While Alzheimer's disease is a neuropathological diagnosis, the importance of establishing a presumptive diagnosis which can be employed for investigational as well as clinical use is underscored. This paper proposes a diagnostic schema which reflects the current understanding of this disorder. There must be evidence of gradual progressive mental deterioration in attention, learning, memory, cognitive style, motivation, and higher order thinking. A comprehensive medical and psychiatric evaluation is obligatory to eliminate reversible physical illness, psychiatric disorder, or cerebrovascular condition as underlying causes of cognitive dysfunction.

Abstract: The diagnostic process not only paves the way for treatment, but also functions as a type of treatment itself. Both behavioral and physical problems can respond to diagnosis properly used as a therapeutic tool. The role of diagnosis in dealing with psychological problems focuses on the ascription of meaning to psychological symptoms through proper diagnosis and effective sharing of that with the patient. The placebo effect is used as a model of how belief and understanding about physical symptoms (derived from the diagnosis) constitute treatment. Finally, it is shown that the meaning which the physician assigns to the disease affects recovery, and a "meaning model" of illness is derived and expanded.

Abstract: Compliance with physician recommendations among long-term hypertensive patients can be a chronic and difficult treatment problem This study evaluated the relative effectiveness of additional patient education and psychosocial counseling in improving patient compliance At a family practice clinic, 123 low income, rural, black hypertensive patients were pretested on several psychological characteristics and randomly assigned to one of three groups: vigorous, group patient education and family physician appointments; supportive, individualized psychosocial counseling and family physician appointments; or family physician appointments only, which was the baseline medical care Intervention and follow-up each lasted three months, and the intervention was in addition to the patients' baseline medical care Compliance was measured by: keeping follow-up appointments; bringing antihypertension medications to each appointment; consuming these medications; and diastolic blood pressure Analysis of variance of group mean and change scores, t tests, and chisquare analysis indicated that neither additional patient education nor additional psychosocial counseling improved compliance or blood pressure control significantly better than regular family physician visits alone

Abstract: Information gained from family studies requires integration in the educational matrix of family medicine To facilitate this activity a model that synthesizes major theories and definitions is presented This paper describes a conceptual model that includes components that have been identified as basic to the recognition and understanding of the family in trouble It is proposed that knowledge of family function as represented in the model, the Cycle of Family Function, will, in turn, help the physician assess and manage problems presented by patients who are victims of stress related to family problems

Abstract: A Patient Panels Registry was developed to study patient identification with family physicians in a large health maintenance organization. There was a clear correlation between the sex of the patient and the sex of the physician. Female patients were 1.49 times as likely as males to select a female physician. Male patients were 1.14 times as likely as females to select a male physician. Women physicians were found to have panels consisting of 66.4 percent female patients, while panels of the male physicians were 53.8 percent female. In order to interact most effectively with both male and female patients, family physicians must be able to recognize their own sex biases as well as those of their patients.

Abstract: Literature of Mexican-American folk medicine and on Mexican-American utilization of conventional medical services suggests that folk medicine and utilization of conventional medical services are related. This study reports on interviews with 40 Mexican-American families randomly selected from the community. The results indicate that choice of conventional medical care and/or folk medicine is dependent upon the symptom, that families often use both folk and conventional medicine, that they are more likely to seek medical help for anxiety than for depression, and that knowledge of folk medicine is best acquired by asking about specific folk diseases. These findings have application in family practice.

Abstract: This paper re-evaluates the concept of the difficult patient from the perspective of the physician-patient relationship. Specifically, patients that physicians define as difficult are seen as the product of failed relationships with physicians. A variety of reasons for failure of relationships between physicians and patients to lead to satisfactory outcomes is discussed. These reasons include failures of communication between patient and physician, failure of physicians to recognize the needs and expectations of patients, and failure of physicians to recognize the symbolic or phenomenological aspects of their patients' illnesses. Teachers of young family physicians need to incorporate models of medical care and compliance which involve the contribution of the physician as well as that of the patient.

Abstract: Accurate self-evaluation is central to a family physician's professional growth both during and after the residency training period. Self-evaluations of residents' interviewing skills, as demonstrated in videotaped interviews with simulated patients, were compared to multiple faculty evaluations as part of an annual assessment. Means for resident evaluations were lower and showed greater variations than faculty ratings but correlated significantly in several areas. Inter-rater reliability coefficients were highest when criteria were most specific. Residents benefited from the opportunity to compare and discuss their perceptions with those of objective and competent raters.

Abstract: Preventive health care has been identified as a major function of the family physician. The ability of the family physician to significantly affect the preventive health status of a patient and his/her family is largely dependent on the preventive health attitudes and health care practices of the patient. This preliminary study identifies some of the attitudes towards preventive health and reported health care practices of a sample of patients in a model family practice unit. The authors found that social position was significantly associated with assessment of personal health, attitudes towards preventive health practices, and attitudes toward the preventive function of the physician. While the majority of the study population was willing to spend time to obtain preventive health care services, the same population was almost evenly divided about their willingness to spend extra money to obtain these services. The physician was cited as the most frequent source of health care information by respondents in this study.

Abstract: This study explores the effect of an increase in the family physician to population ratio on use of the hospital Emergency Department in a community. Two household surveys were conducted, the first before a community health center was established in an underserviced community, the second survey three years later. During this period there was a fivefold increase in the family physician-population ratio. Use of hospital Emergency Departments decreased. Respondents were more likely to have called their physician before going to the Emergency Department. If they did not call, the reason for not doing so was less likely related to physician unavailability. A decrease in the level of perceived illness in the community was also found.

Abstract: Traditional medicine men coexist with physicians and hospitals on the 25,000 square mile Navajo Indian Reservation. Most seriously ill Navajos utilize both systems of health care. This natural experiment of coexistence emphasizes several general characteristics of all healing. Traditional ceremonies are successful because they are integrated into Navajo belief systems and meet needs of sick people not dealt with by the available Western medicine. Physicians and other healers simply remove obstacles to the body's restoration of homeostasis or, as the Navajo say, to harmony. Reductionism limits the spectrum of obstacles considered relevant (eg, causes of illness), but an alternate model might include emotional, social, or spiritual phenomena equally as significant to healing as are biochemical phenomena. In that context, nonmedical healers, as well as physicians, can potentially influence factors relevant to getting well.

Abstract: Using an incremental cost approach, the cost of instruction for medical students participating in a variety of ambulatory-care, chiefly family-practice, experiences in several clinical practice sites was examined. The costs ranged from $5 per student per day for a first-year observational experience to $112 per student per day for a second-year preceptorship with direct patient care involvement by the students. Factors such as the previous experience of the student, the baseline productivity of the site, the number of examining rooms, the income source of the preceptor (salary vs fee-for-service), and the clarity of preceptor role definition are discussed in relation to cost. The lack of defined, stable income to offset costs is noted. In view of the substantial costs of instruction in ambulatory family practice clerkships, clearly defined ongoing sources of income must be provided to ensure the continuation or expansion of these vital experiences.

Abstract: Somatic pain, functional, and anxiety complaints of 154 depressed patients were followed during the course of their initial depression and were found to parallel the depression: these complaints increased in number just prior to diagnosis of depression and decreased to normal levels after one year's treatment of the depression. Persistence of these types of somatic symptoms after one year's treatment predicted eventual chronicity of the depression. Older patients were also more likely to develop chronic depressions, and there was some indication that those individuals who had an initial remission of a depression followed by a second depression which then became chronic had longer first depressions.

Abstract: A self-administered questionnaire assessing sexual satisfaction and presence of a number of common sexual problems was developed. Following assessment of reliability and validity, the questionnaire was administered to 142 patients seen in a family medicine center. While 56 percent of patients reported one or more sexual problems, such problems were noted in the medical record in 22 percent of the cases. The nature of many of the problems (ie, techniques of foreplay, fear of pregnancy, and differences in attitudes and expectations between partners) suggests an effective role in treatment for the primary care physician.

Abstract: This study concerned two questions: Why does the patient come to the physician? And, how does patient-physician agreement as to the primary purpose affect the process and outcome of the medical encounter? Separate interviews of patients and physicians following 200 medical encounters revealed a preponderance of visits for continuing care, a paucity of visits for social and emotional problems, and a number of visits in which "concern" as the patient's primary purpose was misperceived by the physician There was no statistically significant relationship when agreement (or lack of agreement) between patient and physician as to the purpose of the encounter was compared with patient age and sex, number of previous visits of the patient to the physician, and subsequent patient-physician agreement as to the diagnosis, prognosis, therapy, and satisfaction There was also no statistically significant relationship when patient-physician concordance as to visit purpose was compared with education level of the patient or with physician perception of the patient's intended compliance In both concordance and non-concordance groups, physicians underestimated both patient satisfaction with the encounters and intended compliance

Abstract: This study explores the effect of an increase in the family physician to population ratio on use of the hospital Emergency Department in a community. Two household surveys were conducted, the first before a community health center was established in an underserviced community, the second survey three years later. During this period there was a fivefold increase in the family physician-population ratio. Use of hospital Emergency Departments decreased. Respondents were more likely to have called their physician before going to the Emergency Department. If they did not call, the reason for not doing so was less likely related to physician unavailability. A decrease in the level of perceived illness in the community was also found.

Abstract: Medical complaints and office visits of spouses and children of depressed patients were examined and compared to a matched comparison group of spouses and children of nondepressed patients. Both spouses and children of depressed patients showed increased numbers of visits and complaints which returned to control levels one year after the depression was diagnosed and treated. Infection, pain, functional, and anxiety complaints showed significant increases in spouses over controls. Definite diagnoses, infections, pain, and anxiety complaints were significantly increased in children compared to controls. In both spouses and children these complaints returned to control levels by the third period of the study, one year after the depression had been diagnosed (and treatment for depression started). The pain, functional, and anxiety complaints of spouses and children were very similar qualitatively to those of the depressed patients. The results demonstrate the validity of the family as a unit of medical care.

Abstract: The professional definition of the family physician is not based on research that considers both patient and family physician perceptions. Questionnaire responses from 86 family physicians and 287 patients from ten family practices in Los Angeles were analyzed to compare their attitudes, perceptions, and expectations of the family physician. Both groups agreed the family physician could handle most medical problems (including hospital care), should provide continuity, should emphasize preventive medicine, and should be caring. The physician's manner and skill were felt equally important. Family physician and patient expectations conflicted in four major areas: referral, the handling of emotional problems, concern with and care of family, and the issue of autonomy. Such research may help the development of family practice and improve the patient-family physician relationship through improved graduate and continuing medical education for family physicians.

Abstract: Because of its relative youth, family practice research has not yet developed a tradition of proven research techniques. New techniques, even those already proven effective in other disciplines, must be evaluated in the family practice setting if the results that they generate are to have any credibility. The collection of morbidity data has become a major activity in family practice research, but this has occurred without sufficient examination of its reliability. Several problems, both potential and real, exist requiring more detailed scrutiny, discussion, and possibly action. These problems of recording, diagnosis, coding, and population, and their ramifications, are explored with the aim of stimulating such action and encouraging a rigorous approach to the collection, publication, and interpretation of morbidity statistics.

Abstract: The purpose of this study was to compare the obstetrical care provided by three different groups of physicians. Deliveries between July 1975 and July 1977 were tabulated and all 211 deliveries of the family physician (FP) group, and all 199 of the family practice residency (FPR) group were reviewed, as were a randomly selected group of 193 obstetrician (OB) deliveries. All hospital charts were reviewed for 81 variables. The FPR group had more patients who were poor, single, and nulliparous. They presented later in pregnancy, were more often anemic, and had an increased incidence of venereal disease. The FPR and FP groups documented major psychological problems and depression more frequently. The obstetricians used caudal and epidural anesthesia more frequently, whereas the FP and FPR groups used more narcotics. Except for an increased incidence of third degree lacerations in the FP group, total maternal and fetal complications were few and similarly divided among the groups. The FPR and FP groups delivered 78 percent and the OB group 38 percent of their own patients. This paper is an addition to a limited literature base which deals with process and outcome of obstetrical care delivered by various provider groups and is unique in that the study was undertaken in a large prepaid group.

Abstract: A patient questionnaire, chart audit, and resident questionnaire were used to assess clinical breast examination and breast self-examination experience in a family practice patient population. It was found that approximately 50 percent of the women studied reported annual routine breast examinations during a five-year study period. However, the residency program was responsible for providing or documenting annual clinical examinations in only ten percent of the population. Although 99 percent of the women knew about Breast Self-Examination (BSE), only 19 percent practiced monthly BSE. A positive association was found between the physician's active teaching of BSE and the patient's confidence in and regular practice of BSE. The low number of annual clinical examinations and low performance of BSE may be explained partially by the physician's setting too narrowly the parameters of when a clinical breast examination and BSE teaching could be done appropriately, ie, a pap smear/pelvic or general examination. A more aggressive approach by the physician may increase the number of women who get routine clinical breast examinations and who supplement them by monthly BSE.

Abstract: Failure to recognize pseudoseizures is a common problem, affecting both epileptic patients who additionally have pseudoseizures and nonepileptic patients inappropriately called epileptic. Pseudoseizures most commonly mimic generalized tonic-clonic (GTC, "grand mal") seizures or complex-partial seizures. Several patients whose speudoseizures were not recognized are described. Adhering to logical principles of diagnosis for epilepsy, as for other medical problems, and remaining aware of basic beahvioral dynamics should eliminate the confusion between pseudoseizures and epileptic seizures.

Abstract: While the significance of continuity of care in medical practice has not yet been completely assessed, this concept has been espoused by the new specialty of family practice along with some other specialties. It is an integral component in family practice residency programs. The purpose of this paper is to identify several methods of measuring continuity of care in a residency setting and to demonstrate their application. Measurements called COC (Continuity of Care) and UPC (Usual Provider Continuity) will be described as they apply to overall patient visits, visits for chronic conditions, and visits by family members.

Abstract: Very little is known about breast self-examination (BSE), a health practice that has been found to be associated with better clinical and pathological breast cancer outcomes. Using data obtained from a sample of 260 women frequenting three primary care centers, this study investigates rates of BSE and how such rates are affected by social and medical factors. Results indicate that BSE practices are influenced to some extent by a woman's race and level of education, while they are significantly affected by her religion. In contrast, there was no evidence to suggest that a woman's knowledge of breast cancer risk factors, or her own level of risk for the disease, affect the extent to which she is likely to self-examine. These findings suggest the need to confirm these social influences on BSE practice using a larger, population based sample. Moreover, the values and attitudes affecting differential rates of BSE performance should be further investigated.

Abstract: This survey concerning adolescent smoking behavior includes an 82 percent sample of the entire 8th and 11th grades of a rural school. A relatively high incidence of smoking is noted when compared with national statistics. No differences between smokers and non-smokers were found with respect to knowledge of smoking effects, athletic self-perception, or exposure to the smoking behavior of teachers, physicians, dentists, or clergy. Significant differences were found with respect to exposure to the smoking behavior of parents, siblings, and peers. A significant association between smoking males and depression was noted. Efforts are in process to decrease peer smoking exposure by altering school policy. It is predicted that success in decreasing opportunities for exposure will result in a lower incidence of smoking in this population. Language: en