Virginia in the general distribution of Patient Problems in problems by diagnostic categories. the Office Practice of Six Family Physicians Materials and Methods Based on their location, six prac­ in Louisiana tices were selected to participate in the study (Table 1). To facilitate re­ cording and tabulation, the USA Linda C. Stewart, M D, Gerald R. Gehringer, M D, and Modification of the Coded Classi­ Vance G. Byars, Jr, MD fication of Diseases of the British New Orleans and Baton Rouge, Louisiana Royal College of General Practi­ tioners was condensed into a single­ sheet, problem-analysis checklist for the practitioner’s use at the time of the patient encounter (Figure 1). Each physician participated in a brief Using the Royal College of General Practitioners (RCGP) classifi­ orientation to the problem-analysis cation of disease, the patient problems encountered in six family sheet and problems in terminology practice offices were classified. The top 20 diagnoses are identified, were discussed as the study pro­ collectively and individually, and compared with the top 20 diag­ gressed. For example, it was pointed out that should be clas­ noses encountered in a similar, but larger study done in Virginia. sified under circulation and not under The present study includes a regional practice profile based on the digestive tract; a uretheral discharge disease categories of Royal College of General Practitioners, which secondary to gonorrhea should be was compared with the distribution of problems in the Virginia classified under infectious disease and data. This study confirms the Virginia information on the most not under genitourinary problems. While the total number of possible frequently encountered problems. Collectively, southeastern diagnostic choices in the full RCGP Louisiana profiles show fewer respiratory problems and more circu­ Diagnostic Code was 715, this con­ latory problems than the Virginia study. Individually, each practice densation reduced that number to has a distinct enough profile to warrant consideration of individual 250. Data were collected from the six practice profiles at the time of re-certification examination or plan­ offices simultaneously during July and August 1975. ning of continuing education programs.

The medical profession has accum­ encountered problems filed in diag­ ulated much information on the inci­ nostic categories, uses the Coded Results dence of diseases as gleaned from in­ Classification of Diseases of the Table 2 shows the number of surance company reports and hospital British Royal College of General Prac­ problems and patient visits reported. records. However, that information is titioners. The RCGP classification of Clearly, five of the six practices re­ incomplete because the problems of disease is problem oriented, offering corded more than one problem per the non-hospitalized or uninsured pa­ the physician a choice of signs and patient visit, the average being 1.3. tient, recorded only in practicing sym ptom s (vomiting), procedures Practices IV and V did not see a large physicians’ offices, are excluded. In­ (physical examination), and specific volume of patients during the study formation on office problems helps in diseases (diabetes mellitis).2 Recently, period. Eliminating the data from determining the true incidence of the Medical College of Virginia those two practices does not affect specific problems. The British physi­ (MCV) published similar data col­ the statistical interpretation of the cians were the first to collect such lected from physicians’ offices in Vir­ data. information using the E-Book (Diag­ ginia.3 When diagnoses are placed in 17 nostic Index). The E-Book,1 a log of In the course of this study, in­ general diagnostic categories, the dis­ formation was collected on out­ tribution of problems is as shown in patient problems in six practices in Figure 2. For comparison the diag­

From the Department of Family Practice, southeastern Louisiana and compared nostic data from Virginia are given Louisiana State University Medical Center, with those problems reported in the also. Since five categories in the New Orleans, and the F am ily Practice Resi­ dency Program o f Louisiana State U n ive r­ Virginia study. The top 20 diagnoses RCGP classification were omitted in sity at Earl K. Long M em orial Hospital, from the six practices were compared this study, these same categories in Baton Rouge, Louisiana. Requests for re­ prints should be addressed to Dr. Linda C. to each other and collectively to the the MCV data (three percent of Stewart, Earl K. Long M em orial Hospital, MCV’s total data) were likewise ex­ 5825 Airline H ighw ay, Baton Rouge, La Virginia study, and comparisons were also made between Louisiana and cluded.

THE JOURNAL OF FAMILY PRACTICE, VOL. 5, NO. 1, 1977 103 1. Comm unicable 9. Eye ___289 Cirrhosis — 425 Backache ___013 Chicken pox ___179 Cataract ___301 Colic ___420 Bursitis ___004 Gonorrhea ___170 Conjunctivitis ___290 Constipation ___412 Disc ___016 Hepatitis ___180 Glaucoma ___303 Diarrhea/Vomit ___428 Joint pain ___026 Intestinal parasite ___176 Refractive error ___295 Dysphagia — 410 Knee/Meniscus ___011 Measles ___178 Strabismus ___274 Esophogitis — 417 Scoliosis/Kyphosis ___029 Meningitis ___172 Sty ___307 Flatus ___401 Torticollis ___015 Mumps ___177 Ulcer ___287 Gall stones — 421 Tenosynovitis ___012 Rubella ___181 O ther______273 Gastritis — 427 O ther______022 Scabies ___285 Gastroenteritis ___021 Skin fungus 10. Ear ___298 Hepatomeglia 19. Accidents, Poisonings, ___006 Scarlet fever _ 1 8 9 Hearing loss ___283 Hernia V iolence ___003 Syphilis ___161 L a byrinth itis ___284 Umbilical — 478 Dislocation of: ___025 Warts — 182 Otitis externa ___283 Inguinal ___467 Fracture of: ___025 Venereal warts ___183 Otitis media — 284 Hiatal ___477 Finger ___028 O ther______205 T in n itu s ___283 Femoral ___476 Hand ___200 Vertigo ___284 Ventral ___.475 Radius/Ulna 2. Neoplasms ___190 O ther______— 276 Oral cavity ___474 Humerus ___068 Cancer ___279 Peptic ulcer ___473 Clavicle — Type------___285 O ther______467 Vertebra ___066 H odgkin's disease 11. Congenitial Abnormalities ___470 Skull ___433 Circulation ___067 Leukemia 15. G enitourinary ___471 Rib ___435 Digestive ___070 Benign ___322 Breast disorder ___467 Femur — Type------___436 Gastrointestinal ___472 Pelvis ___437 Bone ___332 Cervicitis ___313 Cystitis (acute, chronic) — 469 Tibia/Fibia ___438 O ther______3. A llergic ___342 Dyspareunia ___476 Foot ___086 Asthma ___325 Dysmennorrhea ___477 Toe — 481 Head in ju ry (closed) ___087 Dermatitis 12.Circulatory ___337 Dysuria ___484 Foreign body ___095 Drug allergy ___122 Angina ___320 Epididymitis/Orchitis ___485 Burn — 085 Hay fever ___221 / ___340 Frequency — 485 1st degree ___257 Rhinitis/Sinus ___339 Incontinence ___486 2nd degree ___094 O ther______236 Ascites ___327 Menstrual abnormalities ___487 3rd degree ___212 Cerebral ischemia ___329 Menopause ___488 Overdose 4. Endocrine ___231 Chest pain ___310 Nephritis/Nephrosis — 491 Aspirin — 097 Cushing's syndrome ___215 Congestive heart failure ___316 Prostatitis ___490 Drug ___091 Diabetes ___209 Cor pulmonale ___318 Prostatic hypertrophy — 496 O ther______088 Hyperthyroid ___235 Dyspnea ___323 Salpingitis — 483 Laceration ___089 Hypothyroid ___234 Edema ___31 2 Stone ___094 O ther______— 480 Strain/Sprain ___218 Benign ___315 Urethritis — .494 Other______219 Malign hypertension ___338 Urethral 5. M etabolic ___225 Hemorrhoids ___324 Uterine/Vaginal ___093 G out 20. Prophylactic Procedures ___216 Left ventricular failure prolapse ___092 Hypovitaminosis ___585 Contraceptive ___211 Myocardial infarction ___335 Vaginitis ___096 Lipid abnormality — 543 Immunization (acute) ___344 O ther______101 Obesity — 505 Injection ___229 Pulmonary ___094 O ther______500 Pap test ___223 Peripheral arterial 16. Pregnancy — 511 Physical examination disease 6. Blood — 352 Pregnancy (normal) ___511 Annual ___210 Rheum atic heart disease ___111 Iron deficiency anemia — 362 Pregnancy (problem) — 510 Insurance/School ___233 Syncope ___110 Pernicious anemia — 350 Abortion (spontaneous) ___504 Health education ___228 ___112 Sickle cell anemia — 354 Abortion (incomplete) ___541 Skin test ___224 Varicose ___114 Sickle cell trait ___351 Normal delivery ___505 O ther______227 O ther______114 O ther______— 364 Cesarian section — 363 Postpartum hemorrhage 21. Socioeconomic ___366 O ther______7. Psychological 13. Respiratory ___700 Economic ___139 Addiction (alcohol, ___258 Bronchiolitis — 704 Marital conflict drug) ___254 Bronchiectasis 17. Skin/Hair, etc — 730 Legal problems ___130 Anxiety ___247 Bronchitis (acute, ___369 Acne ___134 Depression chronic) ___394 Bites ___148 Enuresis ___241 Cold (with fever) ___370 Boil, carbuncle, abscess ___145 Frigidity/lmpotence ___240 Cold ___371 C ellulitis ___146 Insomnia ___267 Cough ___380 Dermatitis (contact) ___137 Neurosis ___245 Flu ___378 Dermatitis (seborrhea) ___124 Paranoid states ___255 Emphysema ___395 Erythema ___138 Psychopathic states ___244 Larynx/Trachea ___388 Hair loss ___140 Retardation ___251 Pleurisy ___375 Impetigo ___125 Schizophrenia ___246 Pneumonia ___374 Lymphadenitis ___127 Senility ___257 Rhinitis (no allergy) — 387 Nail disorder — 563 Situational therapy ___243 Sinusitus (acute, ___368 Pityriasis rosea Patient #. _ 1 3 5 Tension headaches chronic) ___396 Pruritus Age------___151 O ther______266 Stridor ___398 Rash ___249 Tonsillar, adenoidal ___390 Ulcer 8. Central Nervous System hypertrophy ___381 Urticaria ___199 A taxia ___256 O ther______399 O ther______195 Coma/Stupor ___1 58 Epilepsy 14. Digestive ___1 59 Migraine ___306 Abdominal pain 18. Bone/Muscle — 169 Neuralgia ___292 Anorexia — 409 Arthritis ___157 Parkinsonism ___309 Anal fistula — 406 Osteo — 168 Sciatica ___283 Appendicitis — 405 Rheumatoid — 160 O ther______300 Ascites ---- 409 Other .

Figure 1. Problem Analysis Sheet

104 THE JOURNAL OF FAMILY PRACTICE, VOL. 5, NO. 1, 1977 Table 1. Types o f Practice by Location Table 2. Number of Problems and Patients Seen

Rural Average Number Total Number Total Number of Problems (Population < 5,000) Practice of Problems of Patients per Patient

II — solo V — solo i 1,882 1,653 1.4

ii 959 909 1.1

Suburban in 989 630 1.6

(Population 5,000-99,000) IV 123 89 1.4

V 286 288 1.0 III — 2 practitioners 1,450 1.6 IV — 2 practitioners VI 2,358 Total 6,597 5,019 1.3

Urban (Population > 100,000)

VI — 18 practitioners I — 2 practitioners

Table 3 lists by practice the 20 most frequent diagnoses. Table 4 ranks the 20 most frequent problems from the combined six practices and compares them with the rank order of the same problems in the Virginia study. Notably, of 715 possible problems in the RCGP Classification of Diseases, south­ eastern Louisiana and Virginia physi­ cians generally encounter the same frequent patient problems. Only five problems in Louisiana are not in the top 20 diagnoses for Virginia; but those five are still within Virginia’s top 51. For another view, Table 5 lists entries from among Virginia’s top 20 diseases which did not appear in the Louisiana top 20 diagnoses.

Discussion When all the problems are com­ pared according to their distribution by diagnostic category (Figure 2), startling differences can be seen be­ tween those from Virginia and south­ eastern Louisiana. Respiratory

t h e JOURNAL OF FAMILY PRACTICE, VOL. 5, NO. 1, 1977 105 problems are preponderant in Vir­ study. often in the Emergency Room than ginia, and more frequent there than In other categories, Virginia had in the doctor’s office. Only a study in Louisiana. However, had the Loui­ more accidents, poisonings, violence, including all facilities offering patient siana data been collected during the and prophylactic procedures handled services could address the question of winter months, the incidence of res­ in the office and fewer pregnancies, which state has more accidents. piratory problems would probably psychological disorders, and allergic, Admittedly, the volume of data in have been greater. Circulatory prob­ endocrine, and metabolic disorders. the Medical College of Virginia study lems, prevalent in Louisiana, occurred However, these differences cannot be far outweighs the 6,596 patient prob­ more frequently there than in Vir­ projected over a 12-month period. lems recorded in this study. Despite ginia. The prevalence of these dis­ Accidents either occur less frequently these limited data, the findings for orders might change in a 12-month in Louisiana or are treated more high-frequency problems compare well

Table 3. Top 20 Diagnoses by Practice

1 II h i IV V VI

1 Physical Pregnancy Pregnancy HBP benign HBP benign HBP benign examination

2 HBP benign HBP benign ASCVD ASCVD Cold (U R I) Physical examination

3 B ronchitis Physical A n xie ty Bronchitis Cold with fever A n xie ty examination

4 Pap smear Prostatitis Diabetes Flu Physical Diabetes examination

5 Tonsillitis Pap smear Physical A n xie ty ASCVD Obesity examination

6 Laceration Diabetes HBP benign Depression A rth ritis Pregnancy

7 Otitis media Tonsillitis CHF Labyrinthitis B ronchitis Depression

8 Obesity C ystitis Osteoarthritis Pap smear A nxiety Asthma

9 Prostatitis Laceration Depression Angina Gastroenteritis Menstrual abnormalities

10 Gastroenteritis Muscle spasm Otitis media Bursitis Osteoarthritis Rash

11 A n xie ty R hinitis Tonsillitis Diabetes Strain/sprain Iron deficiency anemia

12 Cold with fever Otitis externa Low back pain Obesity Boil ASCVD

13 Otitis externa N ephritis Vertigo Physical Contact Cold (U R I) examination derm atitis

14 ASCVD Cold (U R I) Bronchitis Sinusitis Laceration Otitis media

15 Health education CHF Contraception Abdominal pain Cellulitis Vaginitis

16 Spasm Low back D erm atitis Cancer Cystitis Im petigo pain

17 Strain Otitis media Laceration Chest pain Low back pain CHF

18 Cold (U R I) Emphysema Pap smear Cold w ith fever Angina Tension headache

19 Contact Menstrual Peptic ulcer Cystitis Cancer Osteoarthritis derm atitis abnormalities

20 Arthritis Rash Pregnancy Emphysema Cerebral ischemia A bdom inal pain problem —

106 THE JOURNAL OF FAMILY PRACTICE, VOL. 5, NO. 1, 1911 with those of the Virginia study, across Louisiana. Each physician as presented in Tables 4 and 5. Four chooses his or her own style of prac­ Table 5 of the five diagnoses not in Virginia’s tice according to interests. Obviously, Rank Order of Selected Problems top 20 are general categories (other differences occur if one physician in­ genitourinary, other communicable cludes obstetrics, general surgery, or disease, other respiratory, and other pediatrics and another does not. Rank Rank digestive) that were selected be­ Many physicians stress particular in­ MCV SE Louisiana cause a more specific diagnosis was terests within their practices, such as not on the problem-analysis sheet. treatment of obesity, arthritis, or More specific diagnoses were absent emotional problems, and therefore Sprains and because the number of diagnostic attract more patients with these se­ strains 6 37 choices were reduce^ from 715 to lected problems. Febrile cold 250. Pertinent information on the six (URI) 10 31 Table 3 shows the differences that practices is as follows: exist in family physician practices Practice I - a group of two in prac­ Vulvovaginitis/ tice ten and five years respectively; cervix 17 21 includes no obstetrics or surgery. Table 4. Top 20 Diagnoses - Louisiana Abdominal pain Practice II — active more than ten without colic 18 and MCV Study 36 years; includes obstetrics and general surgery.

Rank Rank Practice III — a family physician in he or she is encountering in practice. Order Order partnership with an internist for ten Also, the physician could acquire or Louisiana MCV years; data collected from the family design pamphlets or video tapes for physician’s patients only; includes ob­ patient or nursing-personnel review stetrics. (The family physician’s close using the list of most prevalent diag­ Physical association with an internist might noses encountered. On a larger scale, examination 1 1 have increased the number of internal data illustrating prevalence of certain medicine problems recognized.) diseases could provide a framework Hypertension 2 2 Practice IV - includes no obstetrics for designing local continuing educa­ Pregnancy 3 14 and little pediatrics; group devotes tion programs. The same data based 50 percent of time to neurosurgical on the practices in a state or region Anxiety 4 15 assistance; top 20 diagnoses seem could be beneficial in developing cur­ largely oriented to internal medicine Diabetes 5 7 ricula in medical schools and in resi­ problems. dency training programs. Other Practice V — a physician practicing genitourinary 6 31 for less than five years; includes no obstetrics or surgery. Conclusion ASCVD 7 16 Practice VI — a group practice of 18 Although fewer respiratory prob­ Bronchitis 8 5 in a residency training program; in­ lems were identified, probably be­ cludes obstetrics. cause data were not collected during Obesity 9 9 the winter months, this southeastern Louisiana study confirmed ttye Medi­ Otitis media 10 11 Applications cal College of Virginia’s findings for Depression 11 12 Organized information on the the most common problems in the types of patient problems that are family physician’s office. Further­ Laceration 12 3 occurring in a practice could benefit more, each practice in southeastern Other the practicing physician by serving as Louisiana was found to have a unique communicable a guide for re-certification examina­ practice profile, suggesting the value diseases 13 49 tions and continuing education. The of obtaining practice profiles for use re-certification examinations of the in re-certification examinations and Tonsillitis 14 4 American Board of Family Practice for making informed decisions regard­ Pap smear 15 13 might well be partly based on what ing continuing education for both the physician is currently doing in his physician and patient. Congestive or her practice. The physician could heart failure 16 19 present his or her individual practice

Cold (URI) 17 8 profile, as illustrated by these six References practices, at the time of re-exami­ 1. W arburton SW: " E " Book and its Osteoarthritis 18 35 nation. implications for family practice. J Med Soc NJ 71:553-557 , 1974 Practice profiles could be a basis 2. Rakel R: Practice indexing for the Other for selection of educational material family physician. Cont Ed Fam Physician respiratory 19 22 3(1): 17-21, 1975 for various purposes. The physician 3. Marsland DW, Wood M, Mayo F: Other digestive Data book for patient care, curriculum and 20 51 could choose review courses for con­ research in fa m ily practice: 526,196 pa­ tinuing education according to what tient problems. J Fam Pract 3:25-68, 1976

THE JOURNAL OF FAMILY PRACTICE, VOL. 5, NO. 1, 1977 107