Storylines of family medicine III: core principles-primary care, systems and family

Storylines of Family Medicine is a 12-part series of thematically linked mini-essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'III: core principles-primary care, systems, and family', authors address the following themes: 'Continuity of care-building therapeutic relationships over time', 'Comprehensiveness-combining breadth and depth of scope', 'Coordination of care-managing multiple realities', 'Access to care-intersectional, systemic, and personal', 'Systems theory-a core value in patient-centered care', 'Family-oriented practice-supporting patients' health and well-being', 'Family physician as family member' and 'Family in the exam room'. May readers develop new understandings from these essays.

Addressing Sexual Harassment and Gender Bias: Mandatory Modules Are Not Enough

BACKGROUND AND OBJECTIVES

Despite decades of new policy guidelines and mandatory training modules, sexual harassment (SH) and gender bias (GB) continue in academic medicine. The hierarchical structure of medical training makes it challenging to act when one experiences or witnesses SH or GB. Most trainings designed to address SH and GB are driven by external mandates and do not utilize current educational techniques. Our goal was to design training that is in-person, active, and directed toward skills development.

METHODS

Our academic family medicine (FM) department began by surveying our faculty and residents about their lived experiences of SH and GB. We used these data, incorporating principles of adult learning, to deliver voluntary, experiential, interactive workshops throughout 2019. The workshops took place during faculty development meetings and an annual retreat. We used interactive techniques that included case-based and Theater of the Oppressed formats.

OUTCOMES

Eighty percent of faculty and residents participated in at least one of our voluntary training sessions. In April of 2020, we administered a retrospective, pre/postsurvey on confidence in recognizing, responding to, and reporting SH and GB. We found significant improvements in all domains surveyed; many participants reported using the skills in the 6 months prior to completing the surveys.

CONCLUSION

We demonstrated that voluntary, interactive training sessions using the recommendations of the National Academies of Science Engineering and Medicine Report on the Sexual Harassment of Women improve participants' reported confidence in recognizing, responding to, and reporting SH and GB in one academic FM department. This training intervention is practical and can be disseminated and implemented in many settings.

Evaluating the Uptake of Antiracism Training, Policies, and Practices in Departments of Family Medicine

BACKGROUND

Recent attention and focus on, antiracism training in health care has potential to accelerate our path to social justice and achieve health equity on a national scale. However, theoretical frameworks and empirical data have yet to emerge that explain the uptake of antiracism trainings and their efficacy.

OBJECTIVE

This goal of this study was to test hypotheses regarding uptake of antiracism training in Family Medicine departments using Diffusion of Innovation Theory.

METHODS

In 2021, we incorporated 10 survey items in the Council of Academic Family Medicine Educational Research Alliance's national omnibus survey for Department of Family Medicine Chairs (n = 104). We used DOI (Diffusion of Innovation) attributes (ie, relative advantage, compatibility, complexity, trialability, and observability) as a guiding framework to assess perceived innovation of antiracism training. We also evaluated the mode of training (eg, didactic, experiential) and whether any subsequent policy or practice-level antiracist actions occurred. We used c2 tests to examine associations between DOI attributes and antiracist actions; and logistic regression to determine odds of association.

RESULTS

Ninety-two percent of respondents indicated antiracism training was happening in their department. Relative advantage, compatibility and observability were positively associated with antiracist actions, P < .05. Perceived relative advantage was associated with implementation of antiracist action (OR 1.94, 1.27-2.99). Complexity and trialability were not statistically significantly associated with action.

CONCLUSION

Our findings provide evidence of DOIs influence on antiracism uptake in Departments of Family Medicine. We believe our findings can facilitate the future implementation of antiracism training activities and actionable antiracist policies and practices.

Sexual Harassment and Gender Bias in Family Medicine: Divergent Experiences of Men and Women

Background and Objectives: Awareness of sexual harassment (SH), gender bias (GB), and gender discrimination (GD) has spread throughout popular culture and has been highlighted at universities across the United States. More nuanced data is needed to inform policies that address these issues. However, there are currently limited qualitative studies examining the nature of SH, GB, and GD in academic medicine, particularly family medicine. Methods: In 2018, we conducted a series of gender-specific focus groups with faculty and residents in a department of family medicine (DFM) to understand their experiences with and responses to SH, GB, and GD. The focus groups were transcribed verbatim. We used immersion-crystallization and an adapted SH Experiences model to review the transcripts and identify patterns or themes during the immersion process. Results: Participants identified the potential for patients, colleagues, faculty, and themselves as perpetrators and victims of SH, GB, and GD. Results suggested that GB was often implicit. SH was experienced verbally and physically. Women participants, especially, reported that both SH and GB occurred frequently and had lasting psychological effects. Gender, age, and position (faculty vs trainee) moderated SH and GB experiences. The effects seemed to be mediated by moral distress. Conclusions: This study emphasizes the importance of recognizing differences in experiences across gender, age, and position of SH, GB, and GD in academic family medicine. Our findings can be leveraged to develop antiharassment policies and set cultural expectations.

Empathy and boundary turbulence in cancer communication

OBJECTIVES

To describe and deepen our understanding of patient-centeredness, empathy, and boundary management in challenging conversations. Previous studies show frequent physician self-disclosure, while empathy and boundary management are infrequent.

METHODS

Three standardized patients (SPs) portrayed cancer patients consulting a new community-based physician, resulting in 39 audio-recorded SP visits to 19 family physicians and 20 medical oncologists. Transcripts underwent qualitative iterative thematic analysis, informed by grounded theory, followed by directed content analysis. We further defined the identified communicative categories with descriptive and correlational calculations.

RESULTS

We identified patient-centered physician response categories--empathy, affirmation, and acknowledgement; and physician-centered categories-transparency, self-disclosure, and projection. Acknowledgement and affirmation responses were frequent and empathy rare. Physician transparency and self-disclosure were common. Useful and not useful self-disclosures were highly correlated; empathy, useful and not useful transparency, and projection were moderately correlated. Most physicians used self-disclosure but few of these were judged patient-centered.

CONCLUSIONS

Physicians expressing empathy and patient-centered transparency were also more likely to use projection and physician-centered transparency, thus engaging in communication "boundary turbulence." Patients may benefit from physicians' improved use of empathy and boundary management.

Child Psychiatrists and Psychologists: Enhanced Collaboration in Primary Care

Psychiatry and psychology have a long history of competition that too often interferes with the collaboration that can characterize complementary contributions to our common missions. We hope this article will inspire our disciplines to expand on this collaboration, for the sake of our children and families, our communities, our colleagues, and honestly, ourselves. We are better together than apart. This text is a blueprint for the assumptions, attitudes, skills, and advocacy that can make this partnership healthy and successful.

"Am I Making More of It Than I Should?": Reporting and Responding to Sexual Harassment

BACKGROUND AND OBJECTIVES

Health professionals may face sexual harassment from patients, faculty, and colleagues. Medicine's hierarchy deters response to sexual harassment. Current evidence consists largely of quantitative data regarding the frequency and types of sexual harassment. More information is needed about the nature of the experience and how or why professionals choose to report or respond.

METHODS

We developed and administered a semistructured interview guide to elicit family medicine faculty and residents' experiences with sexual harassment and gender bias. Facilitators led a series of focus groups divided by faculty (N=28) and residents (N=24). We ensured voluntary consent and groups were audiotaped, transcribed and deidentified. We coded the transcripts using immersion-crystallization theory to identify emergent themes.

RESULTS

Sexual harassment from patients and colleagues was described as witnessed or personally experienced by faculty and resident participants in 100% of the focus groups. Respondents identified the presence of mentors, clear reporting process and follow-up, history of good organizational response to reporting, and education and training as facilitators to reporting sexual harassment. Barriers to reporting included fear of retaliation, lack of trust of the system to respond, lack of clarity about "what counts," and confusion with the reporting process.

CONCLUSIONS

It is important to capitalize on facilitators to reporting sexual harassment, starting with acknowledging the frequency of sexual harassment and gender discrimination. Addressing barriers to responding through education and training for our learners and faculty is critical. Clarifying the reporting process, having clear expectations for behavior, and a continuum of responses may help increase the frequency of reporting.

The science of teamwork: Progress, reflections, and the road ahead

We need teams in nearly every aspect of our lives (e.g., hospitals, schools, flight decks, nuclear power plants, oil rigs, the military, and corporate offices). Nearly a century of psychological science has uncovered extensive knowledge about team-related processes and outcomes. In this article, we draw from the reviews and articles of this special issue to identify 10 key reflections that have arisen in the team literature, briefly summarized here. Team researchers have developed many theories surrounding the multilayered aspects of teams, such that now we have a solid theoretical basis for teams. We have recognized that the collective is often stronger than the individual, initiating the shift from individual tasks to team tasks. All teams are not created equal, so it is important to consider the context to understand relevant team dynamics and outcomes, but sometimes teams performing in different contexts are more similar than not. It is critical to have teamwork-supportive organizational conditions and environments where psychological safety can flourish and be a mechanism to resolve conflicts, ensure safety, mitigate errors, learn, and improve performance. There are also helpful teamwork competencies that can increase effectiveness across teams or tasks that have been identified (e.g., coordination, communication, and adaptability). Even if a team is made up of experts, it can still fail if they do not know how to cooperate, coordinate, and communicate well together. To ensure the improvement and maintenance of effective team functioning, the organization must implement team development interventions and evaluate relevant team outcomes with robust diagnostic measurement. We conclude with 3 main directions for scientists to expand upon in the future: (a) address issues with technology to make further improvements in team assessment, (b) learn more about multiteam systems, and (c) bridge the gap between theory and practice. In summary, the science of teams has made substantial progress but still has plenty of room for advancement. (PsycINFO Database Record

The science of teamwork: Introduction to the special issue

Provides an introduction to this special issue which explores the Science of Teamwork-what psychological science in 2018 tells us about the process and outcomes of teamwork in a variety of contexts. This work draws from and affects all areas of psychology. The science and practice of teamwork is now an interdisciplinary activity. Teamwork is a complex phenomenon requiring multiple lenses and approaches. What follows is a description of our process in putting together the issue and a brief description of the articles that compose it. (PsycINFO Database Record

Twenty-five years of education in psychology and psychology in education

This article is part of a special issue of the American Psychologist celebrating the American Psychological Association's (APA's) 125th anniversary. The article reviews the last quarter century (1991-2016) of accomplishments by psychology's education and training community and APA's Education Directorate. The purpose is to highlight key trends and developments over the past quarter century that illustrate ways the Directorate sought to advance education in psychology and psychology in education, as the Directorate's mission statement says. The focus of the Directorate has been on building a cooperative culture across psychology's broad education and training community. Specifically APA has (a) promoted quality education-from prekindergarten through lifelong learning, (b) encouraged accountability through guidelines and standards for education and training, and (c) supported the discovery and dissemination of new knowledge to enhance health, education, and well-being. After identifying challenges and progress, the article discusses the future of the field of psychology and the preparation of its workforce of tomorrow. (PsycINFO Database Record

A Curriculum for an Interprofessional Seminar on Integrated Primary Care: Developing Competencies for Interprofessional Collaborative Practice

Health care is increasingly delivered through team-based, collaborative strategies with interprofessional education as an important mechanism for building interprofessional practice competencies. This paper describes an Interprofessional Seminar on Integrated Primary Care (IS-IPC) designed to meet this educational need with interprofessional team-based learning as the foundation of an iterative process such that education and practice inform one another. The IS-IPC can be used to educate an interprofessional group of learners about key topics relevant to working together in integrated primary care. The IS-IPC describes steps in developing an interprofessional seminar, common challenges, and their solutions in creating interprofessional learning experiences, and eight foundational content modules containing an outline and curricular resources. The IS-IPC facilitates interprofessional educator partnerships at the local level and can be customized to fit the local environment, pedagogical philosophy, and learning objectives.

A New Foundation for the Delivery and Financing of American Health Care

For the past decade, primary care practices across America have worked to implement a practice model called the Patient-Centered Medical Home (PCMH) to revitalize practice, better support clinicians and patients, improve efficiency, and facilitate growth in primary care capacity. In spite of substantial progress, this work has not been matched by sufficient change in the payment system to allow these goals to be accomplished. Nevertheless, improving the quality and availability of primary care remains essential to achieving the goals of the Triple Aim (better health care, better population health, and containment of health care costs). For this to occur, the PCMH model of care must be further refined, and the payment system for primary care must be completely restructured. The need for these changes is urgent. In October 2014, the discipline of family medicine announced a comprehensive strategic plan called Family Medicine for America's Health (FMAHealth). FMAHealth proposes to expand the PCMH care model by fully integrating our nation's behavioral/mental health, public health, and primary care systems to create a new foundation for American health care. Accomplishing these ambitious goals will require a broad coalition of private and public interests across the health care disciplines as well as patients, communities, government, and businesses. These changes require additional infrastructure that existing financing systems do not adequately support, so comprehensive payment reform is essential for large-scale dissemination and sustainability of this model. The new payment model must reward value rather than volume of service and must provide a secure financial foundation for practices designed to care for patients and communities at affordable costs.

Contributions of medical family therapy to the changing health care system

Medical family therapy is a form of professional practice that uses a biopsychosocial approach and systemic family therapy principles in the collaborative treatment of individuals and families dealing with medical problems. It emerged out of the experience of family therapists working in primary medical care settings in the 1980s and 1990s. This article describes how contemporary medical family therapy can contribute to a transformed health care system in four areas: the patient experience of health care, the health of the population, the containment of health care costs, and enhanced practice environments.

A tribute to Frank V. deGruy on the occasion of honoring him with the Donald Bloch Award

Recognizes Frank V. deGruy as the recipient of the Donald Bloch Award. deGruy is a leader in integrated, collaborative primary care. He goes so far as to describe mental health and primary care as inseparable, saying attempts to segregate the two inevitably lead to inferior care. His accomplishments include the presidency of Collaborative Family Healthcare Association, during which he involved the organization in grant-getting, to study all aspects of the implementation of integration on the ground. In addition, he argued for and implemented collaboration with other like-minded organizations.

Physicians criticizing physicians to patients

BACKGROUND

Teamwork is critical to providing excellent healthcare, and effective communication is essential for teamwork. Physicians often discuss patient referrals from other physicians, including referrals from outside their primary institution. Sharing conflicting information or negative judgments of other physicians to patients may be unprofessional. Poor teamwork within healthcare systems has been associated with patient mortality and lower staff well-being.

OBJECTIVE

This analysis explored how physicians talk to patients with advanced cancer about care rendered by other physicians.

DESIGN

Standardized patients (SPs) portraying advanced lung cancer attended covertly recorded visits with consenting oncologists and family physicians.

PARTICIPANTS

Twenty community-based oncologists and 19 family physicians had encounters with SPs.

APPROACH

Physician comments about care by other physicians were extracted from transcriptions and analyzed qualitatively. These comments were categorized as Supportive or Critical. We also examined whether there were differences between physicians who provide supportive comments and those who provided critical comments.

KEY RESULTS

Fourteen of the 34 encounters (41 %) included in this analysis contained a total of 42 comments about the patient's previous care. Twelve of 42 comments (29 %) were coded as Supportive, twenty-eight (67 %) as Critical, and two (4 %) as Neutral. Supportive comments attributed positive qualities to another physician or their care. Critical comments included one specialty criticizing another and general lack of trust in physicians.

CONCLUSION

This study described comments by physicians criticizing other physicians to patients. This behavior may affect patient satisfaction and quality of care. Healthcare system policies and training should discourage this behavior.

Physician Self-disclosure in Primary Care Visits

BACKGROUND

The value of physician self-disclosure (MD-SD) in creating successful patient-physician partnerships has not been demonstrated.

METHODS

To describe antecedents, delivery, and effects of MD-SD in primary care visits, we conducted a descriptive study using sequence analysis of transcripts of 113 unannounced, undetected, standardized patient visits to primary care physicians. Our main outcome measures were the number of MD-SDs per visit; number of visits with MD-SDs; word count; antecedents, timing, and effect of MD-SD on subsequent physician and patient communication; content and focus of MD-SD.

RESULTS

The MD-SDs included discussion of personal emotions and experiences, families and/or relationships, professional descriptions, and personal experiences with the patient's diagnosis. Seventy-three MD-SDs were identified in 38 (34%) of 113 visits. Ten MD-SDs (14%) were a response to a patient question. Forty-four (60%) followed patient symptoms, family, or feelings; 29 (40%) were unrelated. Only 29 encounters (21%) returned to the patient topic preceding the disclosure. Most MD-SDs (n=62; 85%) were not considered useful to the patient by the research team. Eight MD-SDs (11%) were coded as disruptive.

CONCLUSIONS

Practicing primary care physicians disclosed information about themselves or their families in 34% of new visits with unannounced, undetected, standardized patients. There was no evidence of positive effect of MD-SDs; some appeared disruptive. Primary care physicians should consider when self-disclosing whether other behaviors such as empathy might accomplish their goals more effectively.

Physician responses to ambiguous patient symptoms

OBJECTIVE

To examine how primary care physicians respond to ambiguous patient symptom presentations.

DESIGN

Observational study, using thematic analysis within a larger cross-sectional study employing standardized patients (SPs), to describe physician responses to ambiguous patient symptoms and patterns of physician-patient interaction.

SETTING

Community-based primary care offices within a metropolitan area.

PARTICIPANTS

Twenty-three primary care physicians (internists and family physicians).

METHOD

Participating physicians had 2 unannounced SP visits randomly inserted into their daily practice schedules and the visits were audiotaped and transcribed. A coding system focusing on physician responses to concerned patients presenting with ambiguous symptoms was developed through an inductive process. Thematic analyses were then applied to coded data.

RESULTS

Physicians' responses to ambiguous symptoms were categorized into 2 primary patterns: high partnering (HP) and usual care (UC). HP was characterized by greater responsiveness to patients' expression of concern, positivity, sensitivity to patients' clues about life circumstances, greater acknowledgment of symptom ambiguity, and solicitation of patients' perspectives on their problems. UC was characterized by denial of ambiguity and less inclusion of patients' perspectives on their symptoms. Neither HP physicians nor UC physicians actively included patients in treatment planning.

CONCLUSIONS

Primary care physicians respond to ambiguity by either ignoring the ambiguity and becoming more directive (UC) or, less often, by acknowledging the ambiguity and attempting to explore symptoms and patient concerns in more detail (HP). Future areas of study could address whether physicians can learn HP behaviors and whether HP behaviors positively affect health outcomes.

Emotion language in primary care encounters: reliability and validity of an emotion word count coding system

OBJECTIVES

To develop a reliable and valid computer coded measure to assess emotional expression from transcripts of physician-patient interactions.

METHODS

Physician encounters with two standardized patients (SPs) were audiotaped. Fifty patients from each physician (n = 100 primary care physicians) completed surveys that assessed patients' perceptions of their relationships with physicians. Audio-recordings of 193 patient-physician encounters were transcribed and computer-coded to derive a percent emotion words, and research assistants completed the Measure of Patient-Centered Communication (MPCC).

RESULTS

After adjustment for potential confounders, regression analyses revealed physicians' use of emotion words and the MPCC contribute independently to patients' and SPs' perceptions of their relationship with physicians.

CONCLUSIONS

The computerized coding of emotion words shows promise as a reliable, valid, and simple method to code transcript data of physician-patient interactions. This method may be expanded to examine other aspects of physician language and does not require coder training.

The psychotherapy of genetics

The evolution of genomic science and its effect on medicine and health care offer opportunities for family therapists to participate in the comprehensive care of patients and families with genetic disorders. This article provides an overview of what we now know about the psychological and interpersonal experience of patients and families facing some of these illnesses. Case examples illustrate the process of decision-making about testing and treatment, and the importance of understanding developmental issues and transgenerational family dynamics in any related psychotherapy. Challenging emotional issues include managing anger, ambivalence, and guilt; challenging interpersonal issues include dealing with differing coping and communication styles, decisions about disclosure and secrets, and conflict resolution. Family-oriented interventions include individual, couple, and family therapy, and psychoeducational groups. Recommendations are made for family therapists to participate as part of the genetic healthcare team.

Patient Trust

BACKGROUND

Patients' trust in their health care providers may affect their satisfaction and health outcomes. Despite the potential importance of trust, there are few studies of its correlates using objective measures of physician behavior during encounters with patients.

METHODS

We assessed physician behavior and length of visit using audio tapes of encounters of 2 unannounced standardized patients (SPs) with 100 community-based primary care physicians participating in a large managed care organization. Physician behavior was assessed via 3 components of the Measure of Patient-Centered Communication (MPCC) scale. The Primary Care Assessment Survey (PCAS) trust subscale was administered to 50 patients from each physician's practice and to SPs. We used multilevel modeling to examine the associations between physicians' Patient-Centered Communication during the SP visits and ratings of trust by both patients and SPs.

RESULTS

Component 1 of the MPCC, which explored the patient's experience of the disease and illness, was independently associated with patient's rating of trust in their physician. A I SD increase in this score was associated with 0.08 SD increase in trust (95% confidence interval 0.02-0.14). Each additional minute spent in SP visits was also independently associated with 0.01 SD increase in patient trust. (95% confidence interval 0.0001-0.02). Component 1 and visit length were also positively associated with SP trust ratings.

CONCLUSIONS

Physician verbal behavior during an SP encounter is associated with trust reported by SPs and patients. Research is needed to determine whether interventions designed to enhance physicians' exploration patients' experiences of disease and illness improves trust. Key Words: physician-patient relationship, patient-centered care, trust, physician behavior

Family issues in a psychoeducation group for women with a BRCA mutation

Few services exist for women who test positive for BRCA1 and BRCA2 mutations despite the distress that they and their families may experience. We present one model of a time-limited family-oriented psychoeducation group to provide information and support for nine women who received positive test results. We report on five family-oriented themes that arose from the discussions: distress about possible transmission to children; family conflict about testing; concerns about disclosure; different coping styles and decision making; and underlying family conflict and unresolved grief. We also include recommendations from these women to enhance the services available to families by expanding assessment, and providing written literature and contact information. In addition, referrals for a psychoeducation group, community support group, or psychotherapy may be useful for individuals, couples and families who are considering genetic testing for BRCA mutations.

Family interviewing: a review of the literature in primary care

BACKGROUND

Interviewing families is an essential skill for family physicians, but there is little research on the process or outcomes of family interviewing in primary care.

METHODS

We conducted a search of MEDLINE and PsychINFO using a wide range of terms related to family interviewing. The studies obtained were grouped into one of four categories: physicians' family orientation or level of family involvement, family genograms, family members who accompany patients to routine visits, and family conferences.

RESULTS

Family history and other family information are commonly collected, and family issues are often discussed in office visits. Genograms can be reliably and accurately obtained during brief visits, but they are not commonly used, and their impact is uncertain. Family members frequently accompany patients to office visits and serve various roles. The potential benefits and risks of these visits are not fully understood. Family conferences are infrequently used but are well accepted by patients and may be a cost-effective method for reducing unnecessary health care utilization.

CONCLUSIONS

Physicians use a wide range of family interviewing approaches with individual patients, with family members who accompany patients to office visits, and in family conferences. More research is needed to examine the process and outcome of these different types of family interviewing.

Relational therapy in medical settings: working with somatizing patients and their families

Psychotherapy for patients who present in a medical setting involves certain unique challenges, including the need to bridge the mind-body split. Somatizing patients, in particular, live at the interface of mind and body. Their physical symptoms may be biological markers as well as psychological metaphors and interpersonal communications. As such, it is important to assess and treat both patient and family, in collaboration with the healthcare team. We review three foundational principles for working with such families: biopsychosocial integration, development of a collaborative stance, and moving from "Either-Or" to "Both-And" thinking. An extended report of a patient with psychogenic seizures illustrates the use of nine treatment strategies: (1) Validate the reality of the problem, (2) involve the family, (3) work closely with the healthcare team, (4) enhance curiosity, (5) actively attend to somatic symptoms, (6) link the somatic and the psychological. (7) use physical interventions, (8) tolerate uncertainty and practice patience, and (9) terminate gently.

Do physicians who diagnose more mental health disorders generate lower health care costs?

BACKGROUND

Underrecognition and undertreatment of mental health disorders in primary care have been associated with poor health outcomes and increased health care costs, but little is known about the impact of the diagnoses of mental health disorders on health care expenditures or outcomes. Our goal was to examine the relationships between the proportion of mental health diagnoses by primary care physicians and both health care expenditures and the risk of avoidable hospitalizations.

METHODS

We used cross-sectional analyses of claims data from an independent practice association-style (IPA) managed care organization in Rochester, New York, in 1995. The sample was made up of the 457 primary care physicians in the IPA and the 243,000 adult patients assigned to their panels. We looked at total expenditures per panel member per year generated by each primary care physician and avoidable hospitalizations among their patients.

RESULTS

After adjustment for case mix, physicians who recorded a greater proportion of mental health diagnoses generated significantly lower per panel member expenditures. For physicians in the highest quartile of recording mental health diagnoses, expenditures were 9% lower than those of physicians in the lowest quartile (95% confidence interval, 5% - 13%). There was a trend (P = .051) for patients of physicians in the highest quartile of recording mental health diagnoses to be at lower risk for an avoidable hospitalization than those of physicians in the lowest quartile.

CONCLUSIONS

Primary care physicians with higher proportions of recorded mental health diagnoses generate significantly lower panel member costs, and their patients may be less likely to be admitted for avoidable hospitalization conditions.

[Medical family therapy in children with chronic illness]

This article describes a medical family therapy approach to working with families of a child with a chronic medical illness. Medical family therapy combines the systemic paradigm of family therapy with the biopsychosocial paradigm of medicine to treat patients and families who are experiencing medical illness or disability. This article describes how family dynamics influence children's health and how children's health influences family dynamics. It then addresses special assessment issues, treatment issues, and collaboration issues for medical therapists when a child has a chronic illness.