Family Medicine Residency Training Programs Research Articles

Development of Pharmacy Services in a Family Medicine Residency Program

INTRODUCTION Reports of pharmacists working in family medicine settings appeared in the literature as early as 19741 and have continued to the present day.2-28 The role of the pharmacist in this setting has evolved over the past 30 years. In the 1970s most sites had dispensaries, and pharmacists were involved in traditional dispensing functions.1-3,6,7 Pharmacists were also involved in patient care activities (e.g., counselling and taking medication histories), liaising with pharmaceutical company representatives, and providing drug information and education to physicians.1-10 The 1980s saw the expansion of patient care services (i.e., consultations, monitoring, home visits, and liaising with community pharmacists) and the enhancement of services to health care professionals (i.e., education for physicians, residents, and nurses; formulary product selection; and newsletters).11,12,14,15,17-19,21,22 This growth continued into the 1990s, with pharmacists becoming more involved in committee and administrative work as well as research and scholarly activities.23-27,29-33 These changes were especially evident in sites that served as training facilities for family physicians.23,25,27,28,30-33 The first study of pharmacists’ contributions in this setting was reported in 1975. It showed that pharmacists’ consultations with patients regarding their medications and health care needs improved consumers’ attitudes toward pharmacy.3 In a 1979 study, a peer review panel concluded that drug therapy recommendations made by pharmacists and implemented by physicians were appropriate and had favourable effects on patient care.10 Studies published since then have shown that patient-specific consultations and both formal and informal drug-related education provided by the clinical pharmacist improve physicians’ prescribing practices.34,35 Other studies have reported that recommendations made by clinical pharmacists contribute positively to patient care by resolving drugrelated problems or improving the clinical status of the patient.30,36,37 Several studies have described patients’, physicians’, and family medicine residents’ positive perception of clinical pharmacy services.9,12,33,37,38 Other research has demonstrated the positive cost–benefit ratio of clinical pharmacy services in family practice.39-42 Most of the research appears to have been conducted at sites with residency training programs in family medicine.9,10,12,30,33-38 There is, however, a paucity of information on the role or impact of clinical pharmacists in family medicine settings in Canada. The purpose of this paper is to describe the implementation and growth of pharmacy services in a family medicine residency training program in Halifax, Nova Scotia.

Confidence of academic general internists and family physicians to teach ambulatory procedures.

To evaluate and compare the readiness of academic general internal medicine physicians and academic family medicine physicians to perform and teach 13 common ambulatory procedures. Mailed survey. Internal medicine and family medicine residency training programs associated with 35 medical schools in 9 eastern states. Convenience sample of full-time teaching faculty. A total of 331 general internists and 271 family physicians returned completed questionnaires, with response rates of 57% and 65%, respectively. Academic generalists ranked most of the ambulatory procedures as important for primary care physicians to perform; however, they infrequently performed or taught many of the procedures. Overall, compared with family physicians, general internists performed and taught fewer procedures, received less training, and were less confident in their ability to teach these procedures. Physicians' confidence to teach a procedure was strongly associated with training to perform the procedure and performing or precepting a procedure at least 10 times per year. Many academic general internists do not perform or precept common adult ambulatory procedures. To ensure that residents have the opportunity to learn routine ambulatory procedures, training programs may need to recruit qualified faculty, train current faculty, or arrange for academic specialists or community physicians to teach these skills.

Excessive thyroid hormone replacement therapy.

Excessive thyroid hormone replacement carries the potential for serious long-term metabolic complications (e.g., accelerated osteoporosis). The increased bioavailability of commercially available products, along with improved laboratory assays for measuring thyrotropin (TSH), has led to an increased chance of actual or detected iatrogenic hyperthyroxinemia. The purpose of this study was to determine the frequency of excessive prescribing and to examine the impact of changes in potency of replacement thyroid hormone formulations and sensitivity of thyroid function tests on its incidence. A retrospective chart review was done of patients requiring thyroid hormone replacement therapy treated at a university-based, family medicine residency training program. The following information was extracted from each chart: specific thyroid medication (including dose and date of onset of therapy) and thyroid laboratory tests results (including serum thyroxine [T4] and TSH). This information from two different time periods (1975 to 1981 and 1982 to 1989) was compared using one-way analysis of variance. Serum T4 levels were not significantly different between the two time periods, 1975 to 1981 and 1982 to 1989 (8.06 +/- 2.93 micrograms/dl versus 9.0 +/- 03.69 micrograms/dl; NS), despite significant changes in TS serum levels (23.6 +/- 38.9 mIU/mL versus 7.44 +/- 18.7 mIU/ml; P = 0.009) and levothyroxine dosage (184 +/- 59.6 micrograms/d versus 145 +/- 64.1 micrograms/d; P = 0.002). Significantly more patients had low (supersuppressed) TSH levels between 1982 and 1990 than between 1975 and 1981 (33 percent versus 10 percent; P = 0.02.) Excessive thyroid hormone replacement with iatrogenic hyperthyroxinemia is a common occurrence. Clinicians need to be aware of this problem and implement measures (e.g., periodic monitoring of TSH) to minimize the occurrence of overdosing and the potential for long-term complications.

Sixteen years' experience with a required third-year family medicine clerkship at Jefferson Medical College.

Jefferson Medical College has developed a program to successfully meet the goal of teaching ambulatory care to all medical students, by providing each of its 223 third-year students with a required six-week clerkship in family medicine. The structured clerkship takes place at one of seven residency-based family practice centers, is supplemented by a formal curriculum, and is based on the active clinical involvement of caring for patients under full-time family medicine faculty supervision. This clerkship has been in existence for 16 years, and has added over 400,000 student-patient encounters to the clinical education of over 3,500 students. Student evaluations of the clerkship have rated it the highest of the six required core clerkships at Jefferson. In addition, over 16% of Jefferson graduates have entered family medicine residency training programs, a rate higher than that of any other school in the northeastern United States, and significantly higher than the average for all U.S. medical schools (12%). Jefferson's experience suggests that ambulatory care can be taught as a core component of the clinical education of all medical students. To be successful, however, strong institutional support, a structured curriculum, an adequate number of patients, a dedicated faculty, a sufficient number of training sites, an appropriate evaluation process, and significant financial support are all necessary.

Effect of prepaid health plans on a family practice residency.

The rapid growth of prepaid health care plans imposes clinical, financial, and educational changes on residency programs. In the study reported here, the authors examined some perceived and actual effects of such plans on a family medicine center associated with a family medicine residency training program. In the study, 37 residents and 19 faculty members completed a 5-point, 16-item survey covering the effect of the prepaid plans used at the center on the program's practice profile, cost-containment efforts, and education activities over a three-year period. Overall, the respondents agreed with the need for cost containment that accompanied participation in the prepaid plan and agreed that prepaid plans increased the number of patient visits and visits by family members. The residents and faculty members agreed that prepaid patients were more demanding and were seen more often for minor or inappropriate problems. Regarding the educational impact of the prepaid plans, the respondents agreed that they improved their clinical decision-making, and no significant concern regarding limitation of laboratory or consultations was noted. Some of the respondents' perceptions were corroborated by findings in the clinic data base that showed increased numbers of patient visits, more visits by members of the same family, and no significant change in outpatient consultation rates.

Family Practice Physicians' Perceptions of the Usefulness of Drug Therapy Recommendations from Clinical Pharmacists

Family practice physicians' perceptions of the usefulness and clinical outcome of drug therapy recommendations made by clinical pharmacists in a family medicine clinic were determined. For 15 weeks, pharmacists in the clinic recorded all consultations in which they made recommendations about the drug therapy of specific patients. At the time of each consultation, the pharmacists gave the physician a questionnaire designed to gauge the physician's opinion of the usefulness of the consultation. Physicians who implemented the recommendations were sent a second questionnaire and asked to indicate the extent to which the clinical pharmacist influenced their decision to implement the recommendation, the effect the recommendation had on the patient's clinical status, and the usefulness of the recommendation to the patient in ways unrelated to clinical status (such as greater patient acceptance, safety, or lower cost). Five clinical pharmacists provided 59 consultations to 33 physicians. The physicians rated 51 (88%) of the consultations as very useful, and they implemented 78 (98%) of the 80 recommended actions. Of the 56 physicians who attributed their decision to implement the recommendation to their consultation with the clinical pharmacist, 43 believed that the recommendations had improved the clinical status of the patient, and 38 believed that the recommendations were useful to patients in ways unrelated to clinical status. Physicians in a family medicine residency training program had positive perceptions of the usefulness of drug therapy recommendations made by clinical pharmacists. A majority of the physicians believed that the recommendations had a positive effect on patients' clinical status.

Family medicine/family physician, USA, 1986.

This article presents: 1.Historical background in formation of the American Board of Family Medicine. 2.Some general and some specific requirements for family medicine residency training programs. 3.Some requirements for faculty, for the training hospital, and for the family medicine center. 4.Examples of how these requirements have been applied in our family medicine training program. 5.An attempt to redefine the ideal family physician.

A health care psychology internship rotation in family medicine

Abstract This paper describes a health care psychology internship rotation within a family medicine residency training program. The goals of the internship, the role of the psychology intern in this setting, and the interaction process are described. Benefits for the psychology interns and family practice residents include increased knowledge of each other's practice field, increased ability to collaborate in patient care, and the development of mutual respect as a result of such collaboration.