Primary Medical Practice Research Articles

Medical Comorbidity of Major Depressive Disorder in a Primary Medical Practice

Despite much speculation about the relationship between depression and medical comorbidity in primary care settings, few investigators have examined this issue empirically. Using a two-stage screening procedure, we assessed 618 patients aged 18 to 64 years in an academic general medicine clinic. Forty-one patients (6.6%) suffered from a current episode of major depressive disorder (MDD). We compared this group with a 20% random sample of nondepressed patients. While patients with MDD were younger (mean age, 41.1 vs 47.2 years), they were assessed by the Duke University Severity of Illness Scale as having more severe medical illness. Patients with MDD were more likely to have malignant tumors and "ill-defined conditions" than nondepressed patients. The 18 patients with MDD (44%) who were correctly diagnosed by their physicians had less severe medical illness than those whose depression was clinically undetected. A logistic regression model predicting MDD group membership included female gender, younger age, higher Duke University Severity of Illness Scale score, and more frequent inactive ill-defined diagnoses. These findings are consistent with assertions: (1) patients with MDD have more physical illness than nondepressed patients and/or (2) somatic symptoms and disability caused by MDD add to the burden of physical illness.

Primary health care providers' recognition and diagnosis of mental disorders in their patients

Primary care physicians and nurse practitioners are the initial casefinders of mental health problems and major providers of mental health treatment in the United States. However, past studies suggest that such primary care providers often neither recognize nor correctly diagnose their patients' mental disorders. This study compared an HMO's primary providers' direct assessments of the current emotional disorders of patients just seen for an outpatient medical visit with those of mental health professionals assessing the same patients with the Structured Clinical Interview for DSM III R (SCID). Using the SCID-derived diagnosis as the standard, the primary providers failed to recognize almost two-thirds of their patients with a current mental disorder. Although confident in their assessments, the primary providers were also able to correctly identify very few of the specific mental disorders most prevalent in primary medical care practice; they identified only one of the seven depressions, three of the 18 anxiety disorders, and none of the four alcohol or drug abuse disorders. Reasons for these diagnostic discrepancies, comparisons with past studies, and training to improve primary providers' diagnosis of mental disorders in their patients are discussed.

Recognition of Alcoholism and Substance Abuse in Primary Care Patients

Alcohol and other substance abuse are frequently seen in primary medical practice but are underdiagnosed. Forty-two (14%) of 294 adult primary care patients suffered from alcohol or other substance abuse, as diagnosed by a structured psychiatric interview. Primary care physicians identified 17 (40%) of these patients, as well as another patient identified during a six-month follow-up period, as having a substance abuse problem at initial clinical evaluation. Clinically identified substance abusers were older, more likely to be married, and more often used multiple drugs. They more frequently had antisocial personality disorders, while patients not clinically recognized were often depressed. Logistic regression analysis indicated that the presence of antisocial personality, the absence of a coexisting depressive disorder, and better social functioning scores were the factors most strongly associated with clinical recognition. The study suggests clinical judgment issues, which may be useful to physicians in training to improve their recognition and treatment of substance abuse disorders.

An expanded social work role in a university hospital-based group practice: service provider, physician educator and organizational consultant.

This paper reports the development of social work role and functions in a primary medical group practice which was established to replace the general medical clinics of a large urban voluntary teaching hospital in an academic medical center. It traces the shaping and implementation of a role which is functionally integral to the care, teaching and research goals of the practice; is operationalized into its service delivery system; and utilizes a full range of sophisticated social work skills. Along with physicians and nurse practitioners, the social worker is a principal provider of patient care, as well as physician educator and organizational consultant who contributes to coordinated, comprehensive and resource conservative care. Implications for other settings are noted.

Determinants of primary medical practice in adult cancer prevention.

The authors conducted a study of primary care physicians in the province of Quebec to ascertain their patterns of preventive practice with respect to cancer in four anatomic sites: breast, cervix, colon-rectum, and lung. They further explored the data set to elicit the determinants of the patterns of preventive practice. Scales were constructed encompassing practice behaviors for each type of cancer, continuing education intensity, knowledge, and belief. The content of these scales was delineated through factor analysis and their reliability assessed using Cronbach's alpha. Other variables were also considered in the conceptual model. Bivariate analysis and multivariate techniques were used. The models tested contained many significant interaction terms. A limited number of the first-order interactions was explored for each of the dependent variables. Different patterns emerged for each cancer type. Mode of reimbursement, continuing education, gender of physician, provider-related barriers to prevention, and knowledge were found to be the major predictors of prevention scores for the cancers studied, but their relative importance varied according to each cancer. The importance of better understanding the determinants of physician behaviors is emphasized and the existence of several possible explanatory models suggested.

Assessing depression in primary medical and psychiatric practices.

A two-stage assessment of newly admitted outpatients at community mental health centers and primary medical care centers found the Center for Epidemiological Studies Depression Scale to be highly sensitive but relatively nonspecific when compared with assessments of depression by the Diagnostic Interview Schedule. Considerably higher than usual screening scores are recommended with both patient populations to improve the efficiency of the Center for Epidemiological Studies Depression Scale. The reasons for our finding that primary care clinicians underdiagnose depressive disorder while psychiatric clinicians overdiagnose it relative to the Diagnostic Interview Schedule include varied presentations by each sector's patients, differing clinical acumen, and factors affecting third-party reimbursement.

The concept and measurement of continuity in primary care.

Continuity of care, a stated fundamental principle of family medicine, is reviewed in terms of its philosophy and definitions. A model of continuity in primary medical practice is proposed, consisting of five elements: the provider, consumer, encounter type, knowledge base, and environment of continuity. The elements are measurable, some more easily than others. There is need to define and operationalize the model more accurately in order to evaluate continuity in primary care medicine.

Problem-Solving and Decision-Making in Primary Medical Practice [Abridged

Problem-Solving and Decision-Making in Primary Medical Practice [<i>Abridged</i>

The place of general practice.

The editor of this issue sets out the place of primary medical care or general practice in any system of health care and shows that the features and problems are common to all forms of care throughout the world.

Primary health care for the poor in the United States and Canada.

The outflow from the field of primary medical practice has been coupled with the failure of the voluntary insurance system in the United States to pay for the costs of most primary care services. These are facts that are even more applicable to the poor who number between 40 and 50 million persons from the point of view of inability to pay for the skyrocketing costs of health services. In the United States, much primary care for the poor is provided in emergency rooms, charity outpatient clinics, and public health department clinics, and is fragmented between various categorical assistance programs. In contrast, in Canada, primary health care is now a right, whereas it is not in the United States, and so the poor in Canada increasingly obtain their health care within the so–called mainstream system. In the United States a series of new categorical assistance programs have revived the development of the concept of comprehensive, neighborhood–based health centers, but at most 1,500,000 persons obtained care in such centers during 1971. The Meharry Medical College experience in this development is unique and multidimensional. But for the great majority of the poor in the United States, adequate primary health care service and the way to finance it with dignity remains as yet an illusory dream.

Primary Medical Practice: A Psychiatric Evaluation

Primary Medical Practice: A Psychiatric Evaluation

Primary Medical Practice. A Psychiatric Evaluation.

Primary Medical Practice. A Psychiatric Evaluation.

Book Review: Primary Medical Practice.

Book Review: Primary Medical Practice.