An Information Systemfor Family Practice

Part 4: Encounter Data and Their Uses

G.L. Dickie, MB, ChB, J.P. Newell, MD, and M.J. Bass, MD, MScLondon, O n ta r io

This paper describes the ways in which encounter data from the family practice teaching units of the Department of Family Medi­cine, University of Western Ontario, have been used for teaching, service, and research. The fact that family physicians may deal with several problems at one visit is emphasized, as is the need to report morbidity in terms of the population at risk, so that comparisons can be made with other work. The value of encounter data in studies of patient utilization and resident experience is noted. The validity of the data has been examined and the extent of under­recording assessed. The system has helped to encourage the spirit ofinquiry in its users.

The method of gathering data on morbidity in the family practice teach­ing units at the University of Western Ontario has been described in the preceding paper by Newell et al.1 This paper describes some of the uses of these data. It was quickly apparent when we began to define our practice population, that the questions, “Who are our patients?” and, “What prob­lems do they have?” are really inseparable. The answer to one supple­ments the answer to the other. We considered that current morbidity data from our own practice populations would form a firm base for service, education, and research in family medicine. Now, after three years, the encounter data system serves all of these functions to some degree. We certainly have the means to compare our illness patterns with others but, in addition, the staff and residents have an accessible information system that

F ro m th e D e p a r t m e n t o f F a m i ly M ed ic ine , U n iv e rs i t y o f W es te rn O n ta r io , L o n d o n , O n ta r io . Reques ts f o r r e p r in t s sh o u ld be addressed t o D r . G .L . D ic k ie , F a m i ly M e d i ­cal C e n t re , S t. Joseph 's H o s p i ta l , 3 6 2 O x f o r d S t r e e t East, L o n d o n , O n ta r i o N 6 A 1V8.

allows systematic inquiry into the work of the family physician.

Recording of Multiple Problems

Since family physicians frequently deal with more than one problem during an encounter with the patient, the information system was designed to accommodate this. Many studies in the literature of family practice tend to record only the main diagnosis for each patient contact. By examining our data and comparing “Main Diag­noses” with “All Diagnoses,” some interesting differences appear.

Table 1 shows the absolute num­bers and the rates per thousand patients at risk for patients consulting with conditions in the various ICD disease categories. The rank order demonstrates that, apart from Prophy­lactic Procedures, Diseases of the Respiratory System are the most com­mon reasons for doctor-patient en­counters. It should be noted that the data in this Table represent all prob­lems dealt with by the physicians. Table 2 illustrates the different figures which are obtained when morbidity is recorded in terms of All vs Main diagnoses. The differences in the absolute numbers in the various cate­gories reflect the many occasions on

which more than one problem was encountered. The low ratios seen in Table 2 for Pregnancy and Accidents result from the fact that these are seldom of secondary importance at any visit. The higher ratio in the Endocrine and Metabolism category reflects the number of occasions when Obesity is dealt with as a secondary problem. In the Diseases of Blood and Blood Forming Organs category the high ratio relates to Iron Deficiency Anemia and Other Incompletely Diag­nosed Conditions appearing as secon­dary problems. Although the total figures for Congenital Malformations are too small to indicate a trend, the difference may be an artifact caused by the tendency of the recorder to label a highly conspicuous problem, whether it has been dealt with or not.

Comparison with Other Morbidity Data

We have been able to compare our overall morbidity patterns with the Second National Morbidity Survey,2 which was carried out in the United Kingdom by the Royal College of General Practitioners. Comparisons are possible because our morbidity data have been related to the registered patient population. While the Second National Morbidity Survey allowed for the recording of more than one prob­lem, this was not stressed. Thus, to make our data comparable, only main problems have been used. Table 3 shows that our consultation rates tend to be higher for most disease cate­gories, but that the rank order of diagnostic groups is similar. The increased number of consultations in the Prophylactic Procedures group may reflect our heavier emphasis on preventive practices.

A simple comparison of consulta­tion rates in the 18 major disease categories is, at best, crude, and seldom shows major differences be­tween practices. We have found it most helpful to express our morbidity data in terms of rates per thousand patients at risk, in each of the biologi­cal age groups. Table 4 shows part of a detailed breakdown of the Diseases of the Respiratory System, which allows patterns of disease to be discerned.

T H E J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 3 , N O . 6, 19766 39

Table 1. Patients Consulting and Consultation Rates per 1 ,0 00 Population at Risk by Sex and Diagnostic Groups U tilizing A ll Recorded Diagnoses (1 973 )

IC D No.Diagnostic Groups

IC D and Supplem ent Male Female Total

Rate

Male

s / 1 ,0 00 at F

Female

?isk

Total Rank

001-136 Infective and parasitic diseases 519 648 1,167 92.2 98.1 95.4 11

140-239 Neoplasms 83 239 322 14.7 36.2 26.3 15

240-279 Endocrine, n u tritiona l and m etabolic diseases 307 634 941 54.5 96.0 76.9 14

280-289 Diseases of blood and b lood-form ing organs 53 128 181 9.4 19.4 14.8 16

290-315 Mental disorders 846 2,084 2,930 150.2 306.5 239.5 3

320-389 Diseases o f the nervous system and sense organs 895 1,040 1,935 158.9 157.5 158.2 7

390-458 Diseases o f the c ircu la to ry system 690 963 1,653 122.5 145.8 135.1 10

460-519 Diseases o f the respiratory system 1,777 2,265 4,042 315.6 343.0 330.4 2

520-577 Diseases of the digestive system 425 627 1,052 75.5 94.9 86.0 12

580-629 Diseases of the genitourinary system 349 2,094 2,443 62.0 317.1 199.7 5

630-678 Com plications of pregnancy, ch ild b irth , and the puerperium 521 521 78.9 78.9 13

680-709 Diseases o f the skin and subcutaneous tissue 955 1,365 2,320 169.6 206.7 189.6 6

710-738 Diseases of the musculoskeletal system and connective tissue 700 1,023 1,723 124.3 154.9 140.8 9

740-759 Congenital anomalies 16 17 33 2.8 2.6 2.7 18

760-779 Certain causes of perinatal m orb id ity and m orta lity 20 35 55 3.6 5.3 4.5 17

780-796 Symptoms and ill-defined conditions 952 1,717 2,669 169.1 260.0 218.1 4

N800-N999 Accidents, poisonings and violence 957 890 1,847 170.0 134.8 151.0 8

Prophylactic procedures and other medical examinations 2,446 4,531 6,977 434.4 686.1 570.3 1

Total 11,990 20,821 32,811 2,129.3 3,152.8 2,681.7

6 4 0 T H E J O U R N A L O F F A M I L Y P R A C T I C E , V O L . 3 , N O . 6, 1976

For example, Chronic Bronchitis is seen to increase in prevalence with age, and is much more common in the male population in middle age and beyond. The Second National Morbidity Sur­vey shows a similar trend, although the British rates are generally higher for respiratory illnesses. These data form a useful basis for undergraduate teaching concerning common clinical entities in primary care practice.

The Disease Index

On a day-to-day basis, the single most useful product of the informa­tion system is the “ Disease Index.” This is a computer printout which lists, under each diagnostic heading, the chart number, age, sex, and number of visits for each patient who has had that problem dealt with during the year. Visits are categorized as initial or subsequent visits for an episode. The Disease Index permits the rapid identification of patients with specific conditions, and allows an age- sex analysis to be made. It has been used in patient recall — for example, juvenile asthmatics for a newly intro­duced exercise program. It is useful in teaching, since a group of patients’ charts can be quickly accessed for the preparation of relevant material on specific diseases. It provides a starting point for descriptive research into the natural history of disease, and has been used extensively, over the past two years, by residents in family prac­tice. We have printed out Disease Indexes for the entire practice on an annual basis, and on special occasions have produced an index to certain subsets of the user population.

Utilization of Services by Families

Our encounter data have been used to identify the utilization patterns of families. According to Wilson (Wilson JL: Family utilization of a medical centre. Department of Family Medi­cine, University of Western Ontario. Paper in preparation.) patients who attend more frequently than expected tend to be members of families in which other members behave in the same way. Also, as family size

Table 2. Comparison of Recording of "M ain" and "A ll" Diagnoses (1973)

Diagnostic Groups ICD and Supplement

Total Patients Total Patients

ICD No.Consulting

(All Diagnoses)Consulting

(Main Diagnoses) A ll / Main

001-136 Infective and parasitic diseases 1,167 971 1.2

140-239 Neoplasms 322 234 1.4

240-279 Endocrine, nutritional and metabolic diseases 941 570 1.7

280-289 Diseases of blood and blood forming organs 181 107 1.7

290-315 Mental disorders 2,930 2,012 1.5

320-389 Diseases of the nervous system and sense organs 1,935 1,515 1.3

390-458 Diseases of the circulatory system 1,653 1,132 1.5

460-519 Diseases of the respiratory system 4,042 3,463 1.2

520-577 Diseases of the digestive system 1,052 722 1.5

580-629 Diseases of thegenitourinarysystem 2,443 1,846 1.3

630-678 Complications of pregnancy, ch ildb irth , and the puerperium 521 479 1.1

680-709 Diseases of the skin andsubcutaneous tissue 2,320 1,803 1.3

710-738 Diseases of the musculoskeletal system and connective tissue 1,723 1,332 1.3

740-759 Congenitalanomalies 33 16 2.1

760-779 Certain causes of perinatal m orbid ity and m orta lity 53 42 1.3

780-796 Symptoms andill-definedconditions 2,669 1,868 1.4

N800-N999 Accidents, poisonings and violence 1,847 1,663 1.1

Prophylactic procedures and other medical examinations 6,977 5,608 1.2

Total 32,811 25,383 1.3

T H E J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 3, NO. 6, 1976641

Table 3. Patient Consulting Rates per 1 ,0 00 Registered Population — Comparison of University o f Western O ntario Data w ith Second National M o rb id ity Survey

IC D No.Diagnostic Groups

IC D and Supplem ent

WesternO ntario(M ain) Rank

Second National M o rb id ity Survey Rank

001-136 Infective and parasitic diseases 79.4 11 70.7 10

140-239 Neoplasms 19.1 15 12.0 16

240-279 Endocrine, nu tritio n a l and m etabolic diseases 46.6 14 26.0 13

280-289 Diseases o f blood and blood fo rm ing organs 8.7 16 12.1 15

290-315 Mental disorders 164.4 3 109.9 6

320-389 Diseases o f the nervous system and sense organs 123.8 8 113.1 5

390-458 Diseases o f the c ircu la to ry system 92.5 10 66.2 11

460-519 Diseases o f the respiratory system 283.0 2 260.7 1

520-577 Diseases o f the digestive system 59.0 14 60.8 12

580-629 Diseases o f thegenitourinarysystem 150.9 5 74.8 9

630-678 Com plications o f pregnancy, ch ild b irth , and the puerperium 72.5 12 22.4 14

680-709 Diseases o f the skin andsubcutaneous tissue 147.4 6 113.3 4

710-738 Diseases o f the musculoskeletal system and connective tissue 108.9 9 91.3 7

740-759 Congenitalanomalies 1.3 18 2.4 17

760-779 Certain causes of perinatal m orb id ity and m orta lity 3.4 17 0.4 18

780-796 Symptoms andill-definedconditions 152.7 4 141.7 2

N800-N999 Accidents, poisonings and violence 135.9 7 82.5 8

Prophylactic procedures and other medical examinations 458.4 1 138.9 3

increases, there is an increasing per- centage of high user families. These families also tend to have a higher- than-expected number of problems of a social or emotional nature.

Experience of Residents

Recently we have adopted a form of feedback to residents based on the work of Tindall et al.3 They used encounter data in their teaching units to examine the clinical problems dealt with over a six-month period by resi­dents in family medicine, and to compare their experience in specific categories of diseases with that of others in their peer group. Marked deviations from the mean are appropri­ate material for analysis, and possible indicators of a need for a change in exposure or orientation of that resi­dent. Pilot results are encouraging. It is intended that this feedback be pro­vided to our residents every three months, so that the information can be available while there is still time for appropriate change.

Common ConditionsA frequent question is, “What are

the most common conditions in family practice?” Table 5 shows the rank order of the occurrence of common problems. The first column is a reflec­tion of the prevalence of these prob­lems in the community served, while the second relates to the physician’s workload. Thus, the common cold brings more patients to the physician during the year than any other problem, but it is only the eighth most common condition with which the doctor deals in his office. In contrast, the physician or his nurse will fre­quently be attending to allergic patients, although only a small number of patients actually have specific allergies.

6 4 2 T H E J O U R N A L O F F A M I L Y P R A C T I C E , V O L . 3 , N O . 6 , 1976

Table 4. Patients with One or More Episodes of the Specified Condition per 1,000 Patients at Risk

RCGPCode Categories 0-4 5-9 15-24 25-44 45-64 65+ Total

240 Acute nasopharyngitis— non febrileMale 738.8 184.9 116.2 93.8 108.1 115.0 182.9Female 714.0 220.5 183.7 176.5 129.1 109.9 209.4

241 Acute nasopharyngitis Male 9.3 6.6 5.4 12.1 19.9 27.9 11.3Female 14.0 7.8 14.5 14.9 20.3 36.6 15.8

242 Acute pharyngitis and acute tons illitis Male 324.6 212.8 142.5 133.8 77.0 45.3 158.5Female 267.4 252.6 156.5 156.8 94.5 53.9 164.2

243 Acute sinusitis Male 4.1 10.0 22.4 24.8 13.9 14.8Female - 13.3 34.6 25.4 12.9 18.0

244 Acute laryngitis and acute tracheitis Male 31.7 12.3 9.1 11.5 14.9 13.9 13.6Female 34.9 6.9 6.6 21.8 15.2 19.4 15.1

245 Epidemic influenza Male 11.2 4.9 4.5 12.1 11.2 7.0 8.4Female 9.3 13.0 9.1 9.6 14.2 36.6 12.6

246 Pneumonia including pneumonia of newborn Male 29.9 16.4 16.3 23.6 14.9 48.8 21.3Female 37.2 18.2 16.9 11.7 33.5 66.8 23.0

247 Acute bronchitis and b ronch io litis Male 156.7 46.8 66.2 53.3 80.7 128.9 72.2Female 150.5 38.2 62.8 87.7 85.4 90.5 77.4

248 Chronic bronchitis Male 0.8 2.7 5.4 21.1 55.7 8.2

Female — 3.6 6.4 6.1 19.4 5.0

T H E J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 3 , N O . 6, 19766 4 3

Table 5 . Rank Order o f the Occurrence of Com m on Problems

Patients V isiting A t Least Once

FrequencyRank Visits

Preventive Exam inations, etc 1 Preventive Exam inations, etc

Coryza 2 Specific allergies

A n x ie ty state 3 Depression

Febrile sore th roa t 4 Hypertension

Depression 5 Fam ily re lationship problems

Lacerations, etc 6 Normal pregnancy

Fam ily relationship problems 7 A n x ie ty state

A cute o tit is media 8 Coryza

Hypertension 9 Febrile sore th roa t

Obesity 10 A cute o titis media

Abdom inal pain 11 Obesity

Bronchitis 12 Lacerations, etc

Validity of Encounter Information

One of the problems in this or any other system is the error that can be introduced at a number of points in the collection process. Few published studies quantify this error, and there­fore it is difficult to determine whether our information system is similar to others in this regard.

A study of a random sample of 108 charts was undertaken to determine the accuracy of the information. Comparison was made between the encounter data recorded and the information in the chart. A number of items were examined, and the follow­ing results obtained. There was no error in chart numbering. Sex and date of birth both showed errors of two percent. Fewer problems appeared on the encounter form than were recorded in the clinical note, exact matching occurring in 85 percent of cases. The coding of diagnoses, which is done by support personnel, was accurate in 84 percent of cases, but within the limits of broad disease categories, accuracy increased to 95 percent. Gruer noted that, even with experience in coding, an error of one to three percent could be expected.4

In a s t udy coordinated by Bentsen,5 59 resident-patient encoun­ters were directly viewed by pairs of

experienced physician observers, who prepared lists of the problems dealt with during the observed encounters. These lists were compared to the encounter forms completed by the residents. The results showed that, on average, 2.54 problems were dealt with at each encounter, but only 1.51 were recorded. This represents a significant loss of data during the first step of information recording, and has great implication for workload studies and for morbidity recording. The secon­dary problems dealt with, but not recorded, may have been entered into the system at an earlier encounter or, if they persist, may be recorded at a later date.

Conclusion

The information system allows us to examine the morbidity patterns of registered teaching practices, which are generally representative of the city of London.6 Flexibility in the system permits the presentation of data in a variety of formats for service, educa­tional, and research uses. We have utilized the data for internal compari­son of the practice patterns of physicians at staff and resident levels. The data are useful as a resource in the preparation of teaching materials, both undergraduate and postgraduate. The

possibilities for inter-center compari­sons are now being explored. Patients with high-risk conditions can be identified. Future developments in our computing techniques may allow direct recall of patients at predeter­mined intervals. The availability of a registered patient population, from which control groups can be prepared without difficulty, makes the informa­tion system an ideal base for clinical operational and educational research. Perhaps one of the most significant aspects of the system is that it involves all residents and medical students who pass through the teaching practices. They can see at first hand the benefits of information which can be obtained by simple techniques of recording. It is hoped that they will be encouraged to institute similar inquiry in their own practices.

Acknowledgem entsT h e m a n y in d i v id u a ls w h o have assisted

in t h e p la n n in g and i m p l e m e n t a t i o n o f this sys tem w i l l re c o g n iz e t h e f r u i t s o f their la b o r . A l l m e m b e rs , past and p resen t , o f the R e c o rd s and Research C o m m i t t e e o f the D e p a r t m e n t o f F a m i l y M e d ic in e , worked p a in s ta k in g ly o n th i s p r o j e c t . Drs. Carol B u c k and J . W a n k l i n f r o m th e D epar tm en t o f E p id e m io lo g y a nd P re v e n t iv e Medicine, m ade i m p o r t a n t c o n t r i b u t i o n s in th e initial phases o f d e v e lo p m e n t . V i s i t i n g professors, Drs . B .G . B e n tse n and D . L . Crombie b r o u g h t t o th e s y s te m t h e i r e xpe r t ise and e x p e r ie n c e . D r . I .R . M c W h in n e y prov ided c o n t in u i n g e n c o u r a g e m e n t and th o u g h t fu l adv ice t h r o u g h o u t t h e p r o j e c t . T o all of these, t h e a u t h o r s e x te n d t h e i r m o s t sincere g r a t i t u d e .

T h i s s ys te m w a s f u n d e d in p a r t , during its d e v e lo p m e n ta l s tage, b y a D e m o n s t ra t io n M o d e l G r a n t ( D . M . 4 6 ) f r o m th e Onta r io M i n i s t r y o f H e a l th .

References1. N e w e l l JP, D ic k i e G L , Bass MJ: An

i n f o r m a t i o n s y s te m f o r f a m i l y p ra c t ic e . Part 3 : G a th e r i n g e n c o u n te r data . J F a m Pract 3 : 6 3 3 - 6 3 6 , 1 9 7 6

2. R o y a l C o l leg e o f G ene ra l Practi ­t io n e rs : M o r b i d i t y S ta t i s t i c s f r o m General P r a c t i c e — S e c o n d N a t io n a l S tudy 1 9 7 0 - 1 9 7 1 . L o n d o n , H er M a je s ty 's S ta t io ­n e ry O f f i c e , 1 9 7 4

3. T i n d a l l H L, H e n d e rs o n R A , C o le AF: E v a lu a t in g f a m i l y p r a c t ic e re s id e n ts w i t h a p r o b le m c a te g o ry in d e x . J F am Pract 2 : 3 5 3 - 3 5 8 , 1 9 7 5

4. G r u e r K T : L iv in g s to n N e w T o w n — U s ing a c o m p u t e r f o r genera l p rac t ice records . J R C o l l Gen P ra c t 2 2 :1 0 0 - 1 0 7 , 1 9 7 2

5. B en tsen B G : T h e a c c u ra c y o f reco rd ­ing p a t i e n t p r o b le m s in f a m i l y p rac t ice . J M e d E d u c 5 1 : 3 1 1 - 3 1 6 , 1 9 7 6

6. Bass M J , N e w e l l JP, D ic k i e G L : An i n f o r m a t i o n s ys te m f o r f a m i l y p ra c t ic e . Part 2: T h e va lu e o f d e f in i n g th e p r a c t ic e p o p u la ­t i o n . J F a m P ra c t 3 : 5 2 5 - 5 2 8 , 1 9 7 6

6 4 4 T H E J O U R N A L O F F A M I L Y P R A C T I C E , V O L . 3 , N O . 6 , 1976

Continued from page 582

contributed to “prevention of disease onset, reduction of morbidity, elimina­tion of disease or delay of death” with one of the therapeutic modalities avail­able to him. I do agree that outcome measures are the most desirable mea­sure of quality of care, but such measures have not been shown to be practical in a real health-care delivery setting.

Dr. Buttery proposes the use of disease rates in the community popula­tion as a basis for comparison with those rates seen by the practicing physician. Such an approach is unwise for several reasons. The first is that accurate information about the preva­lence of diseases in the community is not available. The primary source of this information has been the National Health Interview Survey.8 Two studies which compared these interview re­sponses with data derived from physi­cians’ medical records suggest that the survey information from interview does not conform even moderately well with diseases inferred from physi­cian reporting.9,10 Secondly, even if such information were available, it is unsound to compare morbidity rates in physicians’ patient populations with those of the community because the community contains both patients who seek medical care and those who do not. The prevalence rates may be different in these two populations and comparisons would, therefore, be meaningless. It is, however, rational to compare one physician’s morbidity rates with those of his peers. Appropri­ate adjustments are made for differ­ences in population structure.

I agree that a physician’s patient population may represent a biased sample of the community, although the bias is likely to be less for family physicians (who do not limit access according to patient’s age, sex, or disease) than for other specialists. For the purposes of our project, the impor­tant differences are not those which exist between the patient population and the community, but rather those between the several physicians’ indi­vidual patient populations. Adjust­ments of diagnostic profiles are made for the age and sex differences in the individual population against the total patient population of all the peer physicians. The bias introduced by

examining morbidity profiles of only volunteer physicians is likely to mini­mize differences in physician behavior. Our experience is that there are suffi­cient differences to make analysis worthwhile.

It is necessary to recognize that common diseases occur commonly. Comparison of the several sources of morbidity data in family medicine such as the National Ambulatory Medical Care Survey, the Medical College of Virginia Data, and data from our own program, reveals far more similarities in morbidity profiles than differences. The differences in rates of diagnoses of these common conditions appear to be physician dif­ferences rather than differences in morbidity among the several practice populations. Some reasons for these differences could be a decreased (or increased) sensitivity on the part of the physician, insufficient knowledge of diagnostic criteria, or inadequate data analysis or collection. An analysis of these differences and the provision of appropriate educational material to the physician when indicated cannot help but contribute to better patient care.

Jack Froom, MD University o f Rochester

School o f Medicine and Highland Hospital Rochester, New York

1. Co l ley J R T : Screening fo r disease: Diseases o f the lung. Lance t 2: 1 12 5 -1 12 7 , 1974

2. S a c k e t t D L : Screening f o r disease:Card iovascu lar disease. Lancet 2 : 11891 1 9 1 ,1 9 7 4

3. F ram e PS, Car lson SJ: A cr i t ica l rev iew o f p e r io d ic hea l th screening using spec i f i c screening cr i te r ia , p a r t 1. J Fam Pract 2 :2 9 -36 , 1975

4. F ram e PS, Carlson SJ: A c r i t i c a l r e ­v iew o f p e r io d ic heal th screening using spe­c i f i c screening c r i te r ia , p a r t 3. J. Fam Pract 2: 189 -194 , 1975

5. C onn RB: C u r re n t T h e rap y . P h i la ­de lph ia , W B Saunders, 1976 , p 518

6. D ia m a n t M, D ia m a n t G: Abuse and t im in g o f use o f a n t ib io t i c s in acute o t i t i s media . A rc h O to la ry n g o l 1 0 0 :2 2 6 -2 3 2 , 1974

7. G o ld n e r G M , K n a t te ru d G L , P ro u tT E : E f fec ts o f h y p o g ly c e m ic agents onvascula r c o m p l ic a t io n s in p a t ien ts w i t h a d u l t onset d iabetes: I I I . C lin ica l im p l ic a t io n s o f th e U G D P results. J A M A 2 1 8 :1 4 0 0 -1 4 1 0 ,

1971 / X8. PHS P u b l ic a t io n 1000 : Series 1(1) , 1963

9. PHS P u b l ic a t io n 1000 : Series 2 (7) , 1965

10. PHS P u b l ic a t io n 1000 : Series 2 (23 ) , 1967

Continued on page 646

T H E J O U R N A L O F F A M I L Y P R A C T IC E , V O L . 3 , N O . 6, 1976

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Coding Systems in Family Practice

To the Editor:

I would like to respond to the letter by Dr. Alan J. Bruckheim in the June issue of The Journal o f Family Practice. He raised several issues which have been concerning many of us involved or interested in the classifica­tion and coding of patient problems r ou t i ne l y p r esen t ed to family physicians.

There seems to be a measure of agreement, at least within the educa­tional hierarchy of the discipline, that there is a need for a coded classifica­tion of problems oriented to the needs of family medicine. Some of us feel that the International Classification of Health Problems in Primary Care (ICHPPC) promulgated by the World Organization of National Colleges and Academies of General Practitioners/ Family Physicians (WONC'A) and pub­lished by the American Hospital Association (AHA), represents the best available resource in this area. Time will show whether there is universal agreement as to the appropriateness of this classification, but in the mean­time, to avoid losing access to the data already collected by other classifica­tions such as RCGP(US), 1IICDA, and Canuck, it is necessary to develop transfer codes between ICHPPC and these classifications.

To date, a considerable amount of effort has been put into the develop­ment of such a transfer code between ICHPPC and RCGP(US). Representa­tives of the Department of Family Practice of the Medical University of South Carolina, the Family Medicine Program of the University of Rochester, the Family Practice Resi­dency Program of Lancaster General Hospital, and the Department of Family Practice of the Medical College of Virginia have now reached agree­ment on such a transfer code. These programs have undertaken to use this transfer code on their own data banks and will make it available to any program which wishes to use it.

To avoid the complications in­herent in dealing with such requests on an individual basis, the writer, acting

on behalf of this working group, will be seeking an opportunity to publish this transfer code in a future issue of The Journal o f Family Practice. Mean­while, I would like to thank Dr. Bruckheim for his kind remarks and for raising the issue in this column.

Maurice Wood, MD Medical College o f Virginia

Richmond, Virginia

Depersonalization in Medicine

To the Editor:

It would be easy to react to your editorial, “On Depersonalization in Medicine” (J Fam Pract 3:239, 1976) by asking, “ So what else is new?” Concern for the loss of human values in medicine goes back at least to Sir William Osier and undoubtedly still farther. And yet the problem persists, perhaps because there are so many forces pulling in the other direction. It would be appropriate to look at some of these forces in the hope that identi­fying them will make them easier to combat:

1. The medical college admissions process tends to select students of high intellectual ability with little reference to their emotional makeup or capacity for empathy. This stems partly from the inadequacy of our tools for mea­suring personal qualities and partly from widespread resistance to using them to select medical students. Given the present limits of our ability to measure psychological factors, espe­cially in the medical school application context, this reluctance may be well founded.

2. Until recently there has been woefully inadequate emphasis in medi­cal education upon insuring that the young physician understands and is comfortable with his own feelings. It is a truism that one must be comfortable with oneself before one can deal ade­quately with the feelings of others.

Family medicine has had much to say in this area, and all of medical educa­tion has benefited as a result.

3. Another sort of selection pro­cess is operative at the time of comple­tion of medical education, with those students of highest intellectual attain­ment being encouraged to stay in the academic setting. This tends to perpetuate the overemphasis on intel­lectual characteristics in medical education centers.

4. People naturally tend to con­cern themselves with the problems that appear most urgent to them, and matters of interpersonal relationships often seem less pressing to the physi­cian than the urgent threats to life or bodily integrity that make up a major part of medical practice.

5. Given the realities of physician- patient relationships, patients seldom confront doctors directly with re­quests for sympathy or understanding. Such requests are likely to be masked as physical symptoms or hidden behind a veneer of indifference or hostility. The practitioner unskilled in interpersonal relationships is likely to be totally unaware of the messages his patients are trying to convey.

6. Educators tend to measure that which is measurable, and it is virtually impossible to assign meaningful num­bers to characteristics such as compas­sion or facility in interpersonal relations. In this regard I am reminded of the old story of the man who was seen one night scanning the ground beneath a streetlight. A passerby asked what he was doing and he replied that he was looking for his house key. When he admitted that he wasn’t sure where the key had been lost, he was asked why he was searching in this particular location. He responded, “ Because here I can look.”

Clearly, we must continue seeking better ways to communicate with our patients even if this means searching in areas where there is little or no illumi­nation. Nevertheless, the danger of depersonalization in medical care will be with us for the foreseeable future. Essays on this subject must continue to be published at regular intervals to keep us aware of the need to stress the human side of patient care.

Robert D. Gillette, MD Riverside Family Practice Center

Toledo, Ohio

6 4 6 T H E J O U R N A L O F F A M I L Y P R A C T I C E , V O L . 3 , N O . 6 , 1976