What do family physicians see in practice? A.M. WARRINGTON, MB, BS; D.J. PONESSE, MD; M.E. HUNTER, MD; D.A. GRANT, MD; A.V. GRASSET, MB, BS; D.W. GRAY, MD; C.D. HAYWARD, MD; B.F. LONG, MD; G.E.C. MORRISON, MD; D. SUTHERLAND, MD
Health care problems dealt with in their practices were recorded by seven family physicians over a period of 1 year (two others recorded for 3 months), each diagnosis being coded according to the Canuck Disease Classification Index. Problems were classified into four types: physical, psychosocial, diseases of choice (or lifestyle) and diseases of social impact. More than 850/0 of the 23 108 problems recorded were physical in origin and had physical manifestations. More time was spent on routine checkups and treatment of respiratory disease than on any other activity. Venereal disease and alcoholism were infrequent problems. The family physician is in a favourable position to act as health educator and counsellor and must be thoroughly trained in the physical aspects of disease. Sept m6decins de famille ont enrogistre los problemos de soins do sante qu'ils ont eu a affronter dans leur pratique pendant une periode d'un an (deux autres l'ont fait pendant 3 mois); chaque diagnostic a ete codifie solon l'lndice de Classification des Maladies Canuck. Les problemos ont ete classifies selon quatre types: physique, psychosocial, los maladies dues a un choix (ou dues au mode do vie) et les maladies a impact social. Plus do 850/o dos 23 108 probl&mes roncontres etaiont d'origino physique ot comportalont des manifestations physiques. Plus do temps a 6te consacre & des oxamens syst6matiques et au traltoment do troubles rospiratoiros qu'a touts autro activite. Los maladies v6n6rlennos ot l'alcoolisme ont ete raroment roncontres. Le medocin do famillo so trouvo avantagousomont place pour agir comme educateur et consoillor en mati&ro do sant6 ot II dolt connaitre a fond los aspocts physiques do Ia maladlo. Venereal disease (VD) is said to be
reaching epidemic proportions in Canada, at least according to the newspapers. Is this true? How commonly is alcoholism seen as a medical problem? Would it be among the 50 most common conditions seen by family physicians? How common is obesity in this country? How much of the family physician's time is spent dealing with hypertension and diabetes? What about depression, behaviour problems in chilReprint requests to: Dr. AM. Wa.rrington, 147 West 16th St., 3rd floor, North Vancouver, BC V7M 1T3
dren and adolescents, and marital and sex problems: how time-consuming are they in general practice? How does the disease profile discovered in general practice correlate with the pattern of medical education - closely or not at all? To find out what Canadian physicians see in general practice, seven family physicians in North and West Vancouver (the North Shore, a relatively stable, family-type, urban, residential community) recorded the health care problems they dealt with for a year March 1975 to March 1976. Two other family physicians recorded problems for 3 months - March to June 1975. Methods With an E book* each of the physicians recorded each new condition in all patients seen, including recurrences of previously resolved conditions (e.g., a second myocardial infarction). Follow-up visits for the same conditions were not recorded. All office, hospital and emergency room visits, and house calls were recorded. Thus everything that was seen and dealt with was recorded permanently and was instantly available for recall. All problems seen were classified according to the Canuck Disease Classification Index (CDCI), a Canadian adaptation of the Coded Classification of Disease developed by the Royal College of General Practitioners of Great Britain that conforms closely to the International Classification of Disease, Adapted1 (ICDA); it lists 395 different diseases and problems. All nonspecific symptoms for which a diagnosis was not made were recorded as the symptom (e.g., tiredness, chest pain), and as soon as a diagnosis was established it was recorded (e.g., depression, ischemic heart disease). A classification of disease into four categories by origin and manifestation was developed (by D.J.P.). This was given to an independent group at the University of British Columbia (a family physician at the student health services, an epidemiologist and a family practice resident) and each problem seen was assigned to the appropriate *The E book was developed in Great Britain. It is a means whereby a family physician can record quickly information on all patients seen name, date, sex, date of birth, marital status and disease code. Like all things that work well, it is simple. It can also be used to record information on matters other than disease (e.g., intrauterine contraceptive devices, oral contraceptives. inoculations, prescriptions). For further information write to: Research committee, BC chapter, College of Family Physicians of Canada, 1807 West 10th Ave., Vancouver, BC V67 2A9.
354 CMA JOURNAL/AUGUST 20, 1977/VOL. 117
category, as follows: 1. Physical problems: those with physical origins and physical manifestations. 2. Psychosocial problems: those with psychologic or social origins and psychologic or social manifestations. 3. Diseases of choice (or lifestyle): those with psychologic or social origins and physical manifestations. 4. Diseases of social impact: those with physical origins and psychologic or social manifestations. Since the recording family physicians had practised continuously for an average of 6 years at their present locations, most of the problems in their practices should have been diagnosed. Hence, the findings from their records should reflect accurately the disease profile of their practices. Results The total number of visits recorded (excluding repeat and follow-up visits for the same problem) was 23 108. Although 384 of the 395 CDCI diseases and problems were seen, because of space limitation only the absolute numbers and the percentages of the total numbers of cases for the 50 commonest problems (Table I) and 14 less common problems (Table II), included for comparison, are presented.t The distribution of problems according to the four categories is shown in Table III. Discussion Our results indicate that most of the family physician's time is spent dealing with problems having physical origins and physical manifestations. This refutes the view that most of the problems he or she encounters are psychosocial in origin. It has been suggested that the family physician's training should include more psychosocial studies and less study of clinical disease. However, our findings show that the main emphasis in the training of the family physician is placed correctly on the physical aspects of disease. As other studies have shown, the most common illnesses the family physician treats are acute infections of the upper respiratory tract. The lethal diseases - heart disease and cancer take up proportionately little of his or her time, yet the family physician must be properly trained to deal with these diseases knowledgeably when they occur. tAdditional data may be obtained from Dr. Warrington.
Table I-Absolute numbers and percentages of total number of cases for the 50 commonest problems seen by seven family physicians in 1 year and two other family physicians in 3 months in Vancouver Rank no.
Problem/consultation
No. (and %*)
Typet
*Of all 23108 conditions seen. ti = physical problems; 2 = psychosocial problems; 3 = diseases of choice (or lifestyle); 4 = diseases of social impact.
Table Il-Absolute numbers and percentages of total number of cases for 14 less common conditions Type No. (and%) Problem 1 113 (0.49) Hay fever 3 98 (0.42) Chronic ischemic heart disease and angina 2 89 (0.39) Behaviour problems in children and adolescents 1 85 (0.37) Malignantgrowths, all sites 3 71(0.31) Duodenal ulcer 1 69 (0.30) Diabetes 3 65 (0.28) Chronic bronchitis, emphysema and bronchiectasis Alcoholism, alcoholic psychoses and drug dependence as 2 65 (0.28) defined in ICDA 3 49 (0.21) Acute and subacute myocardial infarction 3 40 (0.17) Gonococcal infections, all sites Frigidity, impetence, anhedonia and other psychosomatic 2 35(0.15) diseases of genitourinary system as defined in ICDA 4 33 (0.14) Epilepsy, all types 3 32 (0.14) Stroke 3 4 (0.02) Syphilis, all stages and sites Table Ill-Distribution of the 23108 problems by type* Type No. (and %) 1 19 916 (86.19) 2 1 322 (5.72) 3 1 789 (7.74) 4 81 (0.35) *See second footnote to Table I for definitions.
Table IV-Order of frequency of seven categories of problems presented to family physicians in Vancouver and Virginia2 Rank no. Problemlconsultation Vancouver Virginia General medical examination 1 1 Anxiety 6 15 Hypertension 2 11 Obesity 14 9 Depression 15 12 Headache 39 27 Asthma 30 44
Table V-Average number of cases of four categories of problems presented to family physicians in Vancouver and the United Kingdom3 No. of cases per physician per year Vancouver United Kingdom Depression 33.73 100 Cancer (all sites) 11.33 7-8 Diabetes 9.2 2-4 Chronic bronchitis 8.6 75-100
and the US the general medical examination or routine complete checkup is not a part of general practice in the UK. Depression is treated much more often in general practice in the UK than in Canada, whereas more cases of cancer and considerably more cases of diabetes are diagnosed and treated in Canada than in the UK. For diabetes
the reason for the difference could be the more frequent use of "routine checks" and of investigative facilities in Canada. Chronic bronchitis is rightly called the English disease. Gastrointestinal infections and upsets rank high on Fry's list of common diseases. In our classification there are different categories for gastritis, duodenitis, disorders of stomach function including indigestion, acute gastroenteritis and colitis, nausea and vomiting, and abdominal pain not otherwise specified; if these had been grouped as gastrointestinal infections and upsets the total number of cases would have been 324 (1.4% of the total number of problems) and they would have ranked third in frequency. The family physician should be an expert in dealing with gastrointestinal infections and upsets and with respiratory tract infections. Comparisons with other studies would be much more accurate if agreement could be reached on a standard international classification of disease. Through the efforts of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) an International Classification of Health Problems in Primary Care (ICHPPC) has been devised and is ready for use in research studies.4 On this continent the family physician is in a favourable position to act as a health educator since he spends more time on general medical examinations (for high-risk patients, and routine insurance, job, school, sports and "nondisease" examinations and advice) than on any other single activity. Attention to diet and proper nutrition, advice to stop smoking and to increase physical fitness by appropriate exercise can readily be given at these encounters. Although most of the problems seen by family physicians are physical in .Write for book to American Hospital Association, 840 North Lake Shore Dr., Chicago, IL 60611; price, $4, US funds.
356 CMA JOURNAL/AUGUST 20, 1977/VOL. 117
both origin and manifestation, this does not mean that the psychosocial aspect of medical practice is unimportant. The whole of medical care is based upon the "biopsychosocial"4 or "whole person" concept; the stresses under which the individual lives will affect the illness from which he suffers and this will affect the medical care and management. As collective knowledge of disease processes improves, it may be that some of the problems listed as purely physical will be found to have psychosocial origins (e.g., leukorrhea, low back pain, amenorrhea, menorrhagia, asthma and nonarticular rheumatism). It is also possible that the incidence of colds and flu may be higher among persons with depression and other emotional disturbances. The CDCI includes a variety of symptoms and ill-defined conditions, such as various aches and pains of undetermined origin, weight loss and tiredness. A firm diagnosis was usually made in these instances. Conclusion Our findings bear out the fact that family physicians must be thoroughly trained in the physical aspects of human disease since more than 85% of their work appears, from present knowledge, to be physical in both origin and manifestation. This study has been a stimulating experience and we encourage other physicians to record and report their observations. The next phase of our investigation will be a 2-year study of psychosocial problems and diseases of choice (or lifestyle), in which the problem, not the diagnosis, will be recorded and an attempt made to identify the underlying psychopathogenesis of these disorders. We thank Dr. A.S. Manes, family physician, Vancouver (formerly family practice resident, Vancouver General Hospital), Dr. R. Percival-Smith, family physician at the student health services, UBC, and Professor M. Warner, department of health care and epidemiology, UBC, who classified the problems into types 1 to 4. We also thank Mrs. Monica Hayden, who entered the patient data on the code index cards, and the BC Medical Library service. Support for this study was provided by the British Columbia Medical Services Foundation (Vancouver Foundation) and the Lions Gate Medical Research Foundation. References 1. World Health Organization: International Classification of Disease, Adapted, 8th rev, Geneva, 1963 2. MARSLAND DW, WOOD M, MAYO F: Content of family practice. Part I. Rank order of diagnoses by frequency. Part II. Diagnoses by disease category and age/sex distribution. / Fain Pract 3: 37, 1976 3. FRY J: Common Diseases: Their Nature,
Incidence and Care, Philadelphia, Lippincott, 1974 4. World Health Organization: Preparation of
the Physician for General Practice, Geneva, 1963, pp 31, 54-5
Health care problems dealt with in their practices were recorded by seven family physicians over a period of 1 year (two others recorded for 3 months), each diagnosis being coded according to the Canuck Disease Classification Index. Problems were classified into four types: physical, psychosocial, diseases of choice (or lifestyle) and diseases of social impact. More than 850/0 of the 23 108 problems recorded were physical in origin and had physical manifestations. More time was spent on routine checkups and treatment of respiratory disease than on any other activity. Venereal disease and alcoholism were infrequent problems. The family physician is in a favourable position to act as health educator and counsellor and must be thoroughly trained in the physical aspects of disease. Sept m6decins de famille ont enrogistre los problemos de soins do sante qu'ils ont eu a affronter dans leur pratique pendant une periode d'un an (deux autres l'ont fait pendant 3 mois); chaque diagnostic a ete codifie solon l'lndice de Classification des Maladies Canuck. Les problemos ont ete classifies selon quatre types: physique, psychosocial, los maladies dues a un choix (ou dues au mode do vie) et les maladies a impact social. Plus do 850/o dos 23 108 probl&mes roncontres etaiont d'origino physique ot comportalont des manifestations physiques. Plus do temps a 6te consacre & des oxamens syst6matiques et au traltoment do troubles rospiratoiros qu'a touts autro activite. Los maladies v6n6rlennos ot l'alcoolisme ont ete raroment roncontres. Le medocin do famillo so trouvo avantagousomont place pour agir comme educateur et consoillor en mati&ro do sant6 ot II dolt connaitre a fond los aspocts physiques do Ia maladlo. Venereal disease (VD) is said to be
reaching epidemic proportions in Canada, at least according to the newspapers. Is this true? How commonly is alcoholism seen as a medical problem? Would it be among the 50 most common conditions seen by family physicians? How common is obesity in this country? How much of the family physician's time is spent dealing with hypertension and diabetes? What about depression, behaviour problems in chilReprint requests to: Dr. AM. Wa.rrington, 147 West 16th St., 3rd floor, North Vancouver, BC V7M 1T3
dren and adolescents, and marital and sex problems: how time-consuming are they in general practice? How does the disease profile discovered in general practice correlate with the pattern of medical education - closely or not at all? To find out what Canadian physicians see in general practice, seven family physicians in North and West Vancouver (the North Shore, a relatively stable, family-type, urban, residential community) recorded the health care problems they dealt with for a year March 1975 to March 1976. Two other family physicians recorded problems for 3 months - March to June 1975. Methods With an E book* each of the physicians recorded each new condition in all patients seen, including recurrences of previously resolved conditions (e.g., a second myocardial infarction). Follow-up visits for the same conditions were not recorded. All office, hospital and emergency room visits, and house calls were recorded. Thus everything that was seen and dealt with was recorded permanently and was instantly available for recall. All problems seen were classified according to the Canuck Disease Classification Index (CDCI), a Canadian adaptation of the Coded Classification of Disease developed by the Royal College of General Practitioners of Great Britain that conforms closely to the International Classification of Disease, Adapted1 (ICDA); it lists 395 different diseases and problems. All nonspecific symptoms for which a diagnosis was not made were recorded as the symptom (e.g., tiredness, chest pain), and as soon as a diagnosis was established it was recorded (e.g., depression, ischemic heart disease). A classification of disease into four categories by origin and manifestation was developed (by D.J.P.). This was given to an independent group at the University of British Columbia (a family physician at the student health services, an epidemiologist and a family practice resident) and each problem seen was assigned to the appropriate *The E book was developed in Great Britain. It is a means whereby a family physician can record quickly information on all patients seen name, date, sex, date of birth, marital status and disease code. Like all things that work well, it is simple. It can also be used to record information on matters other than disease (e.g., intrauterine contraceptive devices, oral contraceptives. inoculations, prescriptions). For further information write to: Research committee, BC chapter, College of Family Physicians of Canada, 1807 West 10th Ave., Vancouver, BC V67 2A9.
354 CMA JOURNAL/AUGUST 20, 1977/VOL. 117
category, as follows: 1. Physical problems: those with physical origins and physical manifestations. 2. Psychosocial problems: those with psychologic or social origins and psychologic or social manifestations. 3. Diseases of choice (or lifestyle): those with psychologic or social origins and physical manifestations. 4. Diseases of social impact: those with physical origins and psychologic or social manifestations. Since the recording family physicians had practised continuously for an average of 6 years at their present locations, most of the problems in their practices should have been diagnosed. Hence, the findings from their records should reflect accurately the disease profile of their practices. Results The total number of visits recorded (excluding repeat and follow-up visits for the same problem) was 23 108. Although 384 of the 395 CDCI diseases and problems were seen, because of space limitation only the absolute numbers and the percentages of the total numbers of cases for the 50 commonest problems (Table I) and 14 less common problems (Table II), included for comparison, are presented.t The distribution of problems according to the four categories is shown in Table III. Discussion Our results indicate that most of the family physician's time is spent dealing with problems having physical origins and physical manifestations. This refutes the view that most of the problems he or she encounters are psychosocial in origin. It has been suggested that the family physician's training should include more psychosocial studies and less study of clinical disease. However, our findings show that the main emphasis in the training of the family physician is placed correctly on the physical aspects of disease. As other studies have shown, the most common illnesses the family physician treats are acute infections of the upper respiratory tract. The lethal diseases - heart disease and cancer take up proportionately little of his or her time, yet the family physician must be properly trained to deal with these diseases knowledgeably when they occur. tAdditional data may be obtained from Dr. Warrington.
Table I-Absolute numbers and percentages of total number of cases for the 50 commonest problems seen by seven family physicians in 1 year and two other family physicians in 3 months in Vancouver Rank no.
Problem/consultation
No. (and %*)
Typet
*Of all 23108 conditions seen. ti = physical problems; 2 = psychosocial problems; 3 = diseases of choice (or lifestyle); 4 = diseases of social impact.
Table Il-Absolute numbers and percentages of total number of cases for 14 less common conditions Type No. (and%) Problem 1 113 (0.49) Hay fever 3 98 (0.42) Chronic ischemic heart disease and angina 2 89 (0.39) Behaviour problems in children and adolescents 1 85 (0.37) Malignantgrowths, all sites 3 71(0.31) Duodenal ulcer 1 69 (0.30) Diabetes 3 65 (0.28) Chronic bronchitis, emphysema and bronchiectasis Alcoholism, alcoholic psychoses and drug dependence as 2 65 (0.28) defined in ICDA 3 49 (0.21) Acute and subacute myocardial infarction 3 40 (0.17) Gonococcal infections, all sites Frigidity, impetence, anhedonia and other psychosomatic 2 35(0.15) diseases of genitourinary system as defined in ICDA 4 33 (0.14) Epilepsy, all types 3 32 (0.14) Stroke 3 4 (0.02) Syphilis, all stages and sites Table Ill-Distribution of the 23108 problems by type* Type No. (and %) 1 19 916 (86.19) 2 1 322 (5.72) 3 1 789 (7.74) 4 81 (0.35) *See second footnote to Table I for definitions.
Table IV-Order of frequency of seven categories of problems presented to family physicians in Vancouver and Virginia2 Rank no. Problemlconsultation Vancouver Virginia General medical examination 1 1 Anxiety 6 15 Hypertension 2 11 Obesity 14 9 Depression 15 12 Headache 39 27 Asthma 30 44
Table V-Average number of cases of four categories of problems presented to family physicians in Vancouver and the United Kingdom3 No. of cases per physician per year Vancouver United Kingdom Depression 33.73 100 Cancer (all sites) 11.33 7-8 Diabetes 9.2 2-4 Chronic bronchitis 8.6 75-100
and the US the general medical examination or routine complete checkup is not a part of general practice in the UK. Depression is treated much more often in general practice in the UK than in Canada, whereas more cases of cancer and considerably more cases of diabetes are diagnosed and treated in Canada than in the UK. For diabetes
the reason for the difference could be the more frequent use of "routine checks" and of investigative facilities in Canada. Chronic bronchitis is rightly called the English disease. Gastrointestinal infections and upsets rank high on Fry's list of common diseases. In our classification there are different categories for gastritis, duodenitis, disorders of stomach function including indigestion, acute gastroenteritis and colitis, nausea and vomiting, and abdominal pain not otherwise specified; if these had been grouped as gastrointestinal infections and upsets the total number of cases would have been 324 (1.4% of the total number of problems) and they would have ranked third in frequency. The family physician should be an expert in dealing with gastrointestinal infections and upsets and with respiratory tract infections. Comparisons with other studies would be much more accurate if agreement could be reached on a standard international classification of disease. Through the efforts of the World Organization of National Colleges, Academies and Academic Associations of General Practitioners/Family Physicians (WONCA) an International Classification of Health Problems in Primary Care (ICHPPC) has been devised and is ready for use in research studies.4 On this continent the family physician is in a favourable position to act as a health educator since he spends more time on general medical examinations (for high-risk patients, and routine insurance, job, school, sports and "nondisease" examinations and advice) than on any other single activity. Attention to diet and proper nutrition, advice to stop smoking and to increase physical fitness by appropriate exercise can readily be given at these encounters. Although most of the problems seen by family physicians are physical in .Write for book to American Hospital Association, 840 North Lake Shore Dr., Chicago, IL 60611; price, $4, US funds.
356 CMA JOURNAL/AUGUST 20, 1977/VOL. 117
both origin and manifestation, this does not mean that the psychosocial aspect of medical practice is unimportant. The whole of medical care is based upon the "biopsychosocial"4 or "whole person" concept; the stresses under which the individual lives will affect the illness from which he suffers and this will affect the medical care and management. As collective knowledge of disease processes improves, it may be that some of the problems listed as purely physical will be found to have psychosocial origins (e.g., leukorrhea, low back pain, amenorrhea, menorrhagia, asthma and nonarticular rheumatism). It is also possible that the incidence of colds and flu may be higher among persons with depression and other emotional disturbances. The CDCI includes a variety of symptoms and ill-defined conditions, such as various aches and pains of undetermined origin, weight loss and tiredness. A firm diagnosis was usually made in these instances. Conclusion Our findings bear out the fact that family physicians must be thoroughly trained in the physical aspects of human disease since more than 85% of their work appears, from present knowledge, to be physical in both origin and manifestation. This study has been a stimulating experience and we encourage other physicians to record and report their observations. The next phase of our investigation will be a 2-year study of psychosocial problems and diseases of choice (or lifestyle), in which the problem, not the diagnosis, will be recorded and an attempt made to identify the underlying psychopathogenesis of these disorders. We thank Dr. A.S. Manes, family physician, Vancouver (formerly family practice resident, Vancouver General Hospital), Dr. R. Percival-Smith, family physician at the student health services, UBC, and Professor M. Warner, department of health care and epidemiology, UBC, who classified the problems into types 1 to 4. We also thank Mrs. Monica Hayden, who entered the patient data on the code index cards, and the BC Medical Library service. Support for this study was provided by the British Columbia Medical Services Foundation (Vancouver Foundation) and the Lions Gate Medical Research Foundation. References 1. World Health Organization: International Classification of Disease, Adapted, 8th rev, Geneva, 1963 2. MARSLAND DW, WOOD M, MAYO F: Content of family practice. Part I. Rank order of diagnoses by frequency. Part II. Diagnoses by disease category and age/sex distribution. / Fain Pract 3: 37, 1976 3. FRY J: Common Diseases: Their Nature,
Incidence and Care, Philadelphia, Lippincott, 1974 4. World Health Organization: Preparation of
the Physician for General Practice, Geneva, 1963, pp 31, 54-5
