Letters to R eferences 1. Geyman JP, Brown TC, Rivers K Referrals in fam ily practice: A Compaq five study by geographic region and the Editor practice setting. J Fam Pract 3:163,1975 2 . Slabaugh RC, Ringiewicz M, Babi- neau RA: The hospital work at a family practice group in a medium sized com­ munity in New England. J Fam Pract 1V 287, 1980 The Journal welcomes Letters to the Editor; if found suitable, they will be published as space allows. Letters should be typed double-spaced, should not exceed 400 words, and are subject to abridgment and other editorial changes in accordance with journal style. Use of the Family APGAR To the Editor: Over the past four years, Smilk- stein et al have published several articles13 in the Journal o f Family Practice concerning the validity and reliability of the Family The Consultation Note both the patient’s outpatient and APGAR questionnaire as a meas­ hospitalized care. A consultation ure of family function. The ques­ To the Editor: note should therefore be consid­ tionnaire was designed to measure Family physicians provide the ered one of the key elements in a a family member's satisfaction with major portion of the primary care successful consultation. five empirical components of fam­ for their patients. Studies have The consultation note should ily function. Since the publication shown that family physicians han­ include (1) a brief statement of the of their first paper in 1978, Smilk- dle 95 to 98 percent of the definitive problem and reason for the consul­ stein et al have attempted to vali­ care for their patients in the office.1 tation, (2) a master problem list to date the instrument by administer­ Similarly, family physicians main­ put the present illness into per­ ing it to married university stu­ tain a large portion of the direct spective for the consultation, (3) dents, adult community mental care for their hospitalized patients. history and physical findings that health patients, college students in In the hospital setting, however, pertain to the present consultation, an introductory psychology course, the consultation or referral rate is (4) laboratory and x-ray findings, adults in a university psychiatric much higher.2 The total care of the current and attempted therapies, clinic, Taiwanese students aged 10 family cannot be met by any single (5) specific questions the family to 13 years, and last, new patients physician. When more specialized physician wants answered, (6) a in a university family medical care is needed, the continuum of statement specifying the level of practice. care naturally extends into the care desired of the consultant, ie, I applaud the efforts of Dr. arena of consultation and referral. consultation vs referral, and (7) a Smilkstein and colleagues. The de­ The consultation process breaks statement requesting follow-up. velopment of an instrument for the down when open communication is The consultation note is not so rapid screening of family function not maintained. If this occurs, con­ radical an idea as it may first is beneficial to both practitioners tinuity of care is lost, and the appear. Although it requires more and researchers interested in family patient is the one who ultimately time on the part of the family phy­ epidemiology and health care utili­ suffers. sician to formulate and write, the zation. At the Duke University A written consultation note or benefits of providing optimal con­ Family Medicine Center, a similar form better defines the patient’s sultant care for the patient are sure­ instrument has been developed problems, workups done, reasons ly worth it. over the past two years. Different for consultation, and goals of the Joseph E. Ross, MD family characteristics have been consultation. This form should Office for Family Practice empirically chosen for our ques­ improve communication and better Rockford School of Medicine tionnaire based on our reading of delineate the consultant's role in Rockford, Illinois the social science and family therapy 882 THE JOURNAL OF FAMILY PRACTICE, VOL. 16, NO. 5, 1983 LETTERS TO THE EDITOR literature. I have administered the comparison is not valid because respond to Dr. Hoffman’s letter in questionnaire to 154 individuals different facets of a patient’s well­ which he questioned the efficacy of from 128 separate families. I have being are measured in each study the Family APGAR in identifying not used the same criteria as and that the study populations are psychosocial problems. In this Smilkstein to validate this instru­ not comparable. connection I would like to make the ment, but a comparison of my initial I am concerned, however, that following comments: findings with those of Smilkstein the Family APGAR questionnaire 1. The Family APGAR is a serves to highlight problems facing may be relatively insensitive, lead­ screening instrument for family investigators of family function. ing to falsely labeling sick families function. The questionnaire consists of 13 as well families. This is important 2. One cannot always equate the questions with the total score rang­ because physicians who are sensi­ level of family function with the ing from 0 to 100. Equal to or below tive to family problems may easily psychosocial status of the patient. 62 was empirically defined as a identify patients with highly dys­ A patient with family dysfunction sick or poorly functioning family. functional families. But a family will almost invariably manifest Twenty-four percent of the inter­ function questionnaire, if it is to be psychosocial problems; however, viewees in my study scored in the valuable, must entice patients who patients with psychosocial prob­ poorly functioning category. In two otherwise would discuss with their lems may not have family dysfunc­ articles recently published in the physician only somatic complaints tion. Psychosocial problems result Journal,4-5 the percentage of pa­ to reveal dissatisfaction with their from stressful life events that are tients with psychosocial diagnoses family and its functioning. By ask­ not buffered or modified by a pa­ in family practices in Sacramento ing only five broad questions, the tient’s resources (primarily family, and Canada ranged from 30.5 to Family APGAR may too easily friends, and groups). Thus one or 33.3 percent. By comparison, the permit a patient to deny family more overwhelming stressful life distribution of Family APGAR problems. events may cause psychosocial problems even with satisfactory scores achieved by patients in the Richard E. Hoffman, MD university family practice showed School of Hygiene and family function. 15.3 percent scored less than 7 out Public Health 3. The goal of the Family APGAR questionnaire is to help of a total possible score of 10; these Johns Hopkins University respondents were considered to Baltimore, Maryland the physician in assessing whether have moderately to highly dysfunc­ the family is the source of the pa­ References tient’s psychosocial problem or a tional families. The authors3 noted 1. Smilkstein G: The Family APGAR: resource in time of trouble. the bunching of responders at high A proposal for a family function test and Gabriel Smilkstein, MD scores and stated that this ampli­ its use by physicians. J Fam Pract 6:1231, 1978 Department of Family Medicine fied the worth of the Family 2. DelVecchio Good MJ, Smilkstein G, University of Washington APGAR as a screen for patients Good BJ, et al: The Family APGAR index: Seattle, Washington who perceive their family to be A study of construct validity. J Fam Pract 8:577, 1979 dysfunctional. 3. Smilkstein G, Ashworth C, Mon­ At Duke, we have noted that in­ tano D: Validity and reliability of the Fam­ Alcoholism in Family Practice terviewees not uncommonly deny ily APGAR as a test of family function. J Fam Pract 15:303, 1982 family problems and give socially To the Editor: 4. Brennan M, Noce A: A study of pa­ The September 1982 article by desirable responses to our family tients with psychosocial problems in a C. Richard Kirkwood et al on the function questionnaire, thereby fam ily practice. J Fam Pract 13:837, 1981 5. Stumbo D, DelVecchio Good MJ, 50 most common diagnoses in Pa­ falsely elevating their scores. It is Good BJ: Diagnostic profile of a family cific Northwest family practices not clear why the Family APGAR practice clinic: Patients with psychosocial provides a ranked list of these 50 appears to identify a smaller per­ diagnoses. J Fam Pract 14:281, 1982 diagnoses (The diagnostic content centage of poorly functioning fami­ of family practice: 50 most com­ lies in a family practice than in my The preceding letter was referred mon diagnoses recorded in the study or the percentage of persons to Dr. Smilkstein, who responds as WAMI community practices. J with psychosocial diagnoses in the follows: Fam Pract 15:485, 1982). I find it Sacramento and Canadian prac­ distressing, although predictable, tices. Two explanations are that the I appreciate the opportunity to 883 the j o u r n a l o f f a m il y PRACTICE, VOL. 16, NO. 5, 1983 Mazanor® (mazindol) e Wyeth LETTERS TO THE EDITOR Actions— Average magnitude of increased weight loss »fdnn placebo-treated patients in studies of anorectics in genera v narily only a fraction of a pound a week Rate of weight to,, , that alcohol (3031) is not even in ber 1982, present to its parent or­ est in first weeks for both drug and placebo and tends to Z * the top 50, much less in the top five succeeding weeks. Total impact of drug-induced weight i n a Z i’ ganizations a core curriculum on of diet alone must be considered clinically limited * or ten, where it belongs. It is naive occupational medicine for family Indication— Management of exogenous obesity as short termn weeks) adjunct in regimen of weight reduction based on cata to hope that alcoholism is being practice residency programs.