Family Practice Residency Research Articles

Five years of reorganization in the family practice residency program in the Lisbon and Tagus Valley Region in Portugal

Resumo O internato médico em Medicina Geral e Familiar transformou-se entre 1981 e 2010 de um internato hospitalar de três anos para um internato baseado nos Cuidados de Saúde Primários de quatro anos. Em 2015 e 2019 o programa foi revisto e introduziram-se novos métodos de avaliação. A Coordenação de Internato Médico de Lisboa e Vale do Tejo gere a formação de 850 médicos internos, e, perante o aumento no número de médicos internos e com as alterações no programa, organizou a sua metodologia de trabalho à volta de 4 focos de intervenção: 1) Equipas Regionais; 2) Comunicação e decisão; 3) Colaboração interinstitucional; 4) Organização da equipa central em 5 pilares - a capacidade formativa, a formação de médicos internos, a avaliação contínua, a formação de médicos orientadores e a avaliação final. Entre 2019 e 2023 foi possível capacitar as equipas regionais, melhorar os processos de tomada de decisão, uniformizar o internato médico, e, a nível central, reforçar a quantidade e qualidade de vagas, aumentar a formação para médicos internos e orientadores, criar equipas de avaliação contínua e contribuir significativamente para o processo de avaliação final a nível nacional.

Cinco anos de reorganização na formação de médicos especialistas em Medicina Geral e Familiar na região de Lisboa e Vale do Tejo em Portugal

Abstract The General and Family Medicine practice residency program was transformed between 1981 and 2010 from a hospital-based 3-year training to a primary health care-based four-year training. In 2015 and 2019, the curriculum changed, and new evaluation methods were introduced. The Lisbon and Tagus Valley Family Practice Residency Coordination manages 850 residents in training, and due to the increase in the number of residents and changes in the curriculum, focused their team on 4 intervention areas: 1) Regional Teams; 2) Communication and Decision; 3) Collaboration; 4) Organizing the Central team around 5 pillars - training capacity, training residents, continuing assessment, training the supervisors, and final assessment. Between 2019 and 2023, they managed to empower the regional teams, improve decision-making, standardized residency programs, and, at the central level, increased the quality and number of the training slots, increased training opportunities for residents and teachers, created continuous evalutaion teams, and contributed significantly to the national final assessment process.

Five years of reorganization in the family practice residency program in the Lisbon and Tagus Valley Region in Portugal

Resumen El internado médico en medicina general y de familia se transformó, entre 1981 y 2010, de un internado hospitalario de tres años a un internado basado en la atención primaria de cuatro años. En 2015 y 2019, el programa fue revisado y se introdujeron nuevos métodos de evaluación. La Coordinación del Internado Médico de Lisboa y Valle del Tajo gestiona la formación de 850 médicos internos y, ante el aumento en el número de médicos internos y las modificaciones en el programa, organizó su metodología de trabajo en torno a cuatro focos de intervención: 1) equipos regionales; 2) comunicación y toma de decisiones; 3) colaboración interinstitucional; 4) organización del equipo central, en cinco pilares: la capacidad formativa, la formación de médicos internos, la evaluación continua, la formación de médicos tutores y la evaluación final. Entre 2019 y 2023 se logró capacitar a los equipos regionales, mejorar los procesos de toma de decisiones, estandarizar el internado médico y, a nivel central, reforzar la cantidad y calidad de plazas, aumentar la formación para médicos internos y tutores, crear equipos de evaluación continua y contribuir de manera significativa al proceso de evaluación final a nivel nacional.

Systematic review of Indigenous cultural safety training interventions for healthcare professionals in Australia, Canada, New Zealand and the United States

ObjectiveTo synthesise and appraise the design and impact of peer-reviewed evaluations of Indigenous cultural safety training programmes and workshops for healthcare workers in Australia, Canada, New Zealand and/or the United...

The Impact of Covid-19 Pandemic on the Education and Wellbeing of the Residents in the Family Practice Residency Program in the Ministry of Health in Bahrain

Background: The global spread of SARS-CoV-2 profoundly affected physicians, especially the trainees in residency programs, in terms of psychological, social well-being, and educational aspects. However, the extent of its impact and how it compromises their quality of life and care has not been established well. Objectives: The aim of our study is to assess the impact of SARS-CoV-2 on psychological, social wellbeing and education among the trainees in residency training programs in the Ministry of Health in the Kingdom of Bahrain. Methods: A cross-sectional study was conducted on 89 trainee residents in February 2022 using the perceived stress questionnaire distributed over social media platforms to be answered online. The questionnaire was composed of 4 parts: demographics, the impact of the COVID-19 virus on psychological well-being, training, and education. A p-value cut-off point of <0.05 at a 95% Confidence Interval (CI) was used to determine statistical significance. Result: Of the 89 questionnaires distributed, 85 trainees responded (95.5%). Residents who covered COVID-19 centers for more than four months had a higher impact on their training than those who covered less than two months. Female trainees were more affected than males. However, there was no significant difference among genders regarding the level of stress and psychological well-being. Conclusion: The adoption of new strategies in the training department for the trainees is recommended to decrease the adverse psychological effects and to prevent any compromise in the training in future pandemics. Keywords: COVID-19, SARS-CoV-2, Pandemic, Trainees, Family Practice, Psychological wellbeing, Residency

Influences on intentions for obstetric practice among family physicians and residents in Canada: an explorative qualitative inquiry

BackgroundMany family medicine residency graduates indicate a desire to provide obstetric care, but a low proportion of family physicians (FPs) provide obstetric care within their practice. This suggests personal preference alone may not account for the low proportion of FPs who ultimately provide full obstetric care. If decisionmakers plan to augment the number of FPs providing obstetric care, barriers to the provision of such care must first be identified. Within this paper, we explore the perspectives of both family practice residents and early-career FPs on the factors that shaped their decision to provide obstetric care.MethodsIn this qualitative study, we analyzed a subset of interview data from three Canadian provinces: British Columbia, Ontario, and Nova Scotia (n = 18 family practice residents; n = 39 early-career FPs). We used thematic analysis to analyze data relevant to obstetric care practice, applying the socio-ecological model and comparing themes across participant types, gender, and province.ResultsParticipants described influences affecting their decision about providing obstetric care. Key influencing factors aligned with the levels of the socio-ecological model of public policy (i.e., liability), community (i.e., community needs), organizational (e.g., obstetric care trade-offs, working in teams, sufficient exposure in training), interpersonal practice preferences (i.e., impact on family life, negative interactions with other healthcare professionals), and individual factors (i.e., defining comprehensive care as “everything but obstetrics”). Many participants were interested in providing obstetric care within their practice but did not provide such care. Participants’ decision-making around providing or not providing obstetric care included considerations of personal preferences and outside influences.ConclusionsIndividual-level factors alone do not account for the decrease in the type and amount of obstetric care offered by FPs. Instead, FPs’ choice to provide or not provide obstetric care is influenced by factors at higher levels of the socio-ecological model. Policymakers who want to encourage obstetric practice by FPs should implement interventions at the public policy, community, organizational, interpersonal, and individual levels.

Outcomes of a rural-focussed family practice residency

Purpose: Family medicine physicians play a crucial role in maternity care in community-based settings. However, residency graduates are decreasingly likely to provide delivery services. We explored residency training and graduates' inclusion of obstetrical care in practice by surveying graduates of the Duluth Family Medicine Residency, traditionally producing a high number of graduates serving rural communities and providing obstetrical care.
 Methods: Graduates (N=48) were surveyed about their provision of maternity care and perceptions of how well the residency prepared them to provide such services. Additional factors that impacted decisions to provide obstetric care (e.g., post-residency training, community size, and if there were obstetricians providing delivery services in their community) were evaluated.
 Findings: Nearly half of graduates (46%) were providing maternity services, most of whom provided perinatal clinical care (68% provided delivery care and 4% operative deliveries). Seventy-one percent worked in a community with an available obstetrician. Graduates providing obstetric services were more likely to live in rural communities (66% vs 35%, p<0.01). Thirty percent of graduates received extra obstetrical training in residency. Graduates providing obstetric services were more likely to cite that their decision to practice obstetrics was influenced by the number of deliveries performed, interactions with attending obstetricians, and interactions with prenatal and laboring patients during residency compared to those not providing obstetric services.
 Conclusions: Residency training has an impact on provision of maternity care and potential practice of family physicians in rural communities. Attention to curricular support, particularly exposure to maternity patients, is important for resident comfort in obstetrics.
 

Needs assessment survey of healthcare providers' perceptions and practices regarding delirium prevention at a university medical center.

Background: Despite the high prevalence and serious implications of delirium, identification, tracking, and documentation of the condition remain a challenge for the health care team, impeding management of patients. This survey is the first phase of a qualitative study to build a conversational agent-based tool for screening and managing delirium-prone patients. Objectives: To assess healthcare providers’ perceptions of delirium management, focusing on patient assessment, therapeutic interventions, and subsequent communication and documentation. Design: An electronic web-based survey was distributed to healthcare providers identified as caring for inpatient acutely ill older adults admitted for medical and orthopedic surgery needs. Respondent contact information was removed to preserve anonymity. Setting: A 1,000 bed university-affiliated teaching hospital in an urban setting. Participants: 23 residents in family practice, 36 residents in internal medicine, and a total of 492 advanced care nurses, nurses, and clinical staff. Approach: The analysis of survey responses provided insight into providers’ current experiences with delirium assessment tools including computerized documentation, as well as their perceptions and attitudes toward delirium prevention. Key results: Most respondents (89%) thought delirium could be prevented, and 85% thought targeting delirium risk factors was helpful. Fifty one percent reported patients’ loneliness and need for companionship, and 65% believed delirium was linked to higher mortality. Only 14% of respondents thought existing Electronic Health Record (EHR) alerts to identify high-risk delirium patients were useful, and 38% thought current delirium assessment protocols were helpful. In addition, 33% of nurses never received formal delirium prevention training, and 48% indicated that they needed improved systems to assess and manage patients at risk for delirium. Conclusion: A majority of providers affirmed that current delirium protocols are helpful; however, existing screening instruments and methods for documentation are cumbersome, resulting in incomplete or limited documentation of episodes. These barriers lead to an understatement of evidence available for continuous improvement of the patient management process.

Searching for the Family Doctor

Searching for the Family Doctor

Notes from the Editor Emeritus, 1996–1998

<h3>Background</h3> Literature suggests that patients who display disruptive behaviours in the consulting room fuel negative emotions in doctors. These emotions, in turn, are said to cause diagnostic errors. Evidence substantiating this claim is however lacking. The purpose of the present experiment was to study the effect of such difficult patients’ behaviours on doctors’ diagnostic performance. <h3>Methods</h3> We created six vignettes in which patients were depicted as difficult (displaying distressing behaviours) or neutral. Three clinical cases were deemed to be diagnostically simple and three deemed diagnostically complex. Sixty-three family practice residents were asked to evaluate the vignettes and make the patient9s diagnosis quickly and then through deliberate reflection. In addition, amount of time needed to arrive at a diagnosis was measured. Finally, the participants rated the patient9s likability. <h3>Results</h3> Mean diagnostic accuracy scores (range 0–1) were significantly lower for difficult than for neutral patients (0.54 vs 0.64; p=0.017). Overall diagnostic accuracy was higher for simple than for complex cases. Deliberate reflection upon the case improved initial diagnostic, regardless of case complexity and of patient behaviours (0.60 vs 0.68, p=0.002). Amount of time needed to diagnose the case was similar regardless of the patient9s behaviour. Finally, average likability ratings were lower for difficult than for neutral-patient cases. <h3>Conclusions</h3> Disruptive behaviours displayed by patients seem to induce doctors to make diagnostic errors. Interestingly, the confrontation with difficult patients does however not cause the doctor to spend less time on such case. Time can therefore not be considered an intermediary between the way the patient is perceived, his or her likability and diagnostic performance.

Where do rural family medicine residents in Canada train?

To report on contextual variance in the distributed rural family medicine residency programs of 3 Canadian medical schools. A constructivist grounded theory methodology was employed. Rural and remote postgraduate family medicine programs at the University of Alberta, the University of British Columbia, and the University of Calgary. Twenty-six family practice residents were interviewed, providing descriptions of 27 different rural sites and 10 regional sites. Interviews were audiorecorded, transcribed verbatim, and thematically analyzed. Participants differentiated between main campus academic health science centres; regional referral hub sites; and smaller, rural, and more remote community sites. Participants described major differences between sites in terms of patient, practice, educational, physical, institutional, and social factors. The differences between training sites included variations in learning opportunities; physical challenges related to weather, distance, and travel; and the social opportunities offered. There were also differences in how residents perceived their training sites, both in terms of what they noticed and how they interpreted their observations and experiences. Although there were contextual differences between regional sites, those differences were a lot less than between different smaller rural and remote sites. These differences shaped the learning opportunities available to residents and influenced their well-being. Although there may be some similarities between distributed training sites, each training context presents unique challenges and opportunities for the family medicine residents placed there. More attention to the specific affordances of different training contexts is required.

Does vaccinating children with the varicella vaccine increase the incidence of shingles in the adult population?

Texas Tech Family Practice Residency at Lubbock Lubbock, TX The corresponding author is Jamie Haynes, MD; [email protected]. The authors declare no conflicts of interest.

Proposta de instrumento de avaliação pedagógica da preceptoria para residências em Medicina de Família e Comunidade

Introdução: Desde a Conferência de Alma-Ata, a importância do cuidado centrado na Atenção Primária à Saúde (APS) foi consolidada como objetivo mundial. No Brasil, a Estratégia Saúde da Família (ESF), composta por equipes multiprofissionais, visa à reorganização da APS, sendo o especialista em Medicina de Família e Comunidade (MFC) o médico indicado para atuação neste campo. A residência em MFC é considerada o padrão ouro da formação desse profissional, porém, para expansão da residência é necessário expansão da preceptoria. Preceptores são profissionais que utilizam seu conhecimento e sua experiência profissional para atuação docente junto aos residentes. No município do Rio de Janeiro houve expansão da APS, com aumento da cobertura ESF de 3,5% para 69,43% em 2018, o que trouxe a necessidade de investimento para expansão da residência, e, desta forma, demandou mais preceptores. No entanto, não pôde ser realizada uma capacitação completa em tempo hábil, sendo desejável que os preceptores continuassem sua qualificação concomitante à preceptoria. Dentre as atividades do preceptor, destacam-se os atributos pedagógicos, relacionados à responsabilidade docente no processo ensino-aprendizagem do residente. Objetivo: Apresentar uma proposta de instrumento para avaliação dos atributos pedagógicos da preceptoria das residências em Medicina de Família e Comunidade. Métodos: Para elaboração da proposta de instrumento para avaliação dos atributos pedagógicos foram realizadas entrevistas compreensivas, com preceptores em Medicina de Família e Comunidade da Universidade do Estado do Rio de Janeiro, segundo um roteiro semiestruturado. Resultados: As entrevistas geraram espaços de reflexão sobre as práticas pedagógicas dos preceptores, motivando-os a construírem novos planos pedagógicos e a repensarem as potencialidades e os obstáculos enfrentados no trabalho pedagógico da preceptoria em MFC. Conclusão: A proposta de um instrumento para avaliação pedagógica se apresentou como formativa para a preceptoria em MFC no âmbito da APS do município do Rio de Janeiro, fazendo supor que produziu ressignificação, precursor de motivação e esperança.

Coronavirus-19 Multisystem Inflammatory Syndrome in Children (MIS-C): A Pediatric Simulation Case for Residents, Fellows, and Advanced Practice Providers.

IntroductionA rare but serious condition often requiring intensive care, multisystem inflammatory syndrome in children (MIS-C) is characterized by hyperinflammatory shock related to the SARS-CoV-2 pandemic. This resource teaches residents, pediatric emergency medicine fellows, and advanced practice providers who care for children to recognize and manage MIS-C and associated sequelae while applying the basic principles of pediatric resuscitation.MethodsThe simulation case was based on a real patient who presented to the emergency department with fever, rash, and cardiogenic shock. We designed the scenario to be used with a high-fidelity school-age mannequin in an emergency center resuscitation room or simulation lab. The case took 25 minutes to run, followed by a 15- to 20-minute debrief session. Personnel required for the case included a simulation technician, case instructor, emergency department nurse, parent, and consultant. Learners had to recognize the syndrome and treat the resultant shock and arrhythmia with a combination of vasopressors, antiarrhythmics, and defibrillation. Afterward, learners participated in a formal debriefing session and completed a written evaluation.ResultsTwenty-five learners (six pediatric emergency medicine fellows, 12 residents, and seven advanced practice providers) participated in the scenario over a 3-month period. The written evaluation was completed by 20 of the 25 participants; all 20 felt their confidence, comfort, and knowledge regarding the topic had increased, with an average score of 5 (strongly agree) on a 5-point Likert scale.DiscussionThis simulation case offers an effective experience for learners to become comfortable and confident in recognizing and managing MIS-C.

Digital Tool to Help Stop Newborn Phototherapy: A Prospective Study

The present study evaluated end-user experience for effectiveness, efficiency, and satisfaction of a mobile application (app) to estimate the risk of rebound hyperbilirubinemia within 72 hours after initial phototherapy ends for infants at 35 weeks’ gestation or longer and age younger than 14 days. This prospective parallel study was performed at one medical center. The 26 participants are neonatology and pediatric and family physicians, neonatal and family nurse practitioners, and family practice residents, who were asked to estimate the risk of rebound hyperbilirubinemia when phototherapy is stopped for a fictional newborn. Participants in Group 1 (no app) were compared with Group 2 (with app). Satisfaction measured from 1 (0%) to 7 (100%). Group 1 had fewer correct answers than Group 2 (38.5% vs. 84.6%; P = .04). The mean satisfaction score for Group 1 was 2, lower than the score for Group 2, 6.6 (P &lt; .001). This provider-developed app is effective and receives high end-user satisfaction.

Does colchicine prevent episodes of recurrent pericarditis in patients who have suffered from acute pericarditis?

Carl R. Darnall Army Medical Center Family Practice Residency Program, Ft. Hood, TX The authors declare no conflicts of interest. The opinions and assertions contained herein are those of the authors and are not to be construed as official or as reflecting the views of the US Army Medical Department, the Army at large, or the Department of Defense.

The Rationale for a Mandatory Antibiotic Stewardship Rotation During Residency: What Worked, What Needs More Work.

Reports of antibiotic stewardship (AS) integration into the > 1000 United States internal medicine and family practice residency core curricula are scarce, but residents value such training. To help address this gap, and the projected shortage of physicians with training for establishing and leading an AS program (ASP), we describe the rationale for, and the output and shortcomings of, a dedicated AS rotation. Residents critically review, in real-time, inpatient antibiotic orders, provide feedback to the prescribers, learn the mechanics and requirements of an ASP, and complete a preliminary quality improvement project. Program evaluations are uniformly positive, noting limited opportunities otherwise to clarify optimal antibiotic choices or discuss antibiotics in depth. Nine posters at national conferences and 1 publication have roots in this rotation. Three alumni matriculated to accredited US infectious diseases fellowships. We invite others to join us in calling for more AS training opportunities during residency.

2373-PUB: Overcoming the Challenges in Discovering Celiac Disease in Type 1 Diabetes Mellitus Focusing on Provider Education

Background: Patients with type 1 diabetes mellitus (DM1) are at risk for having autoimmune conditions such as Celiac Disease (CD). Although uncommon, the presence of CD in a patient with DM1 may result in poor glycemic control, gastrointestinal complaints, nutritional deficiencies, osteoporosis and lymphoma. Recognizing CD is problematic as it is often asymptomatic or presents in an atypical fashion. Despite recommendations from both the ADA and the American College of Gastroenterology our experience suggests there is a general lack of recognition of screening recommendations and presentation in CD particularly in patients with DM1. Methods: Our objectives were three-fold. We first developed a novel on-line assessment program to determine existing knowledge on CD in both medical and family practice residents and faculty. We then developed on-line and direct education to improve knowledge on screening, presentation and diagnosis of CD. Lastly, we have determined the screening rate of adults with a diagnosis of DM1. Results: Our screening rate of at-risk adults with DM1 is less than 20% indicating a poor recognition of CD as a recognized risk. In addition, we determined that CD is rarely considered in patients with DM1 with poorly controlled diabetes even in the context of GI complaints. Our preliminary survey of residents’ knowledge on screening, diagnosis and complications of CD was poor with less than 35% having adequate knowledge status. Conclusion: Screening for CD in our DM1 patients is poor due to lack of knowledge of criteria and screening strategy of providers. This may reflect a significant deficit in resident and faculty knowledge of CD. In addition, CD is rarely considered in symptomatic adults with DM1. We propose our education program aimed at both residents and our faculty will overcome our lack of an organized education program addressing CD and is predicted to improve screening, diagnosis and treatment of adults with DM1 suffering from CD within our population. Disclosure M. Epps: None. M. Fox: None. J. Jafari: None. A. Firek: None.

Perceptions vs Reality of Patient Flow and Workflow in a Primary Care Setting.

Evaluating the time taken at each step in a patient office visit is important for physicians and clinical staff for clinic workflow improvements. Very little data exists on efficiency that is not self-reported by physicians. Employees often have perceptions of the efficiency of a clinic without supporting data. This study examined whether employee perceptions of the amount of patient time spent at various points in the visit matched observed times. Observational cohort study methods and a cross-sectional survey were used in the fall of 2017 in a family practice residency outpatient clinic. Clinical staff (physicians and support staff) were surveyed for their perceptions of patients' time spent at each checkpoint in an office visit. A total of 885 visits were recorded, with 705 being included after review. Time spent at various steps, appointment type, and clinician years of experience were assessed with t-test for statistical significance. The anonymous clinic survey had a 75.5% response rate (37/49) and showed "rooming patients" and "waiting in the exam room to be seen" were the two areas that took longer than expected. The observed data confirmed this perception, showing that rooming and waiting in the exam room each took longer than the staff expected. These values were also greater than available national average times. There was a significant correlation between physician training year and visit length. There was no correlation for nursing experience and patient visit times. The staff-perceived inefficiencies correlated with observed inefficiencies. Addressing these problems would improve patient care and overall clinic workflow.

Development of a Rural Family Practice Rotation in an Athletic Training Residency Program

Context: Postprofessional residency (PPR) programs continue to gain popularity as athletic training education prepares for a paradigm shift. The Commission on Accreditation of Athletic Training Education has established didactic and clinical infrastructure for PPRs seeking accreditation. Accredited programs provide athletic trainers (ATs) with an advanced level of knowledge in a focused area of clinical practice. Objective: A case study report to introduce a novel PPR general medical rotation to illustrate the skills and knowledge of ATs, evaluate the impact of the athletic training residents in the rural family practice (FP) setting, and to discuss how employing an AT in this setting aligns with the triple aim of the Affordable Care Act (ACA). Background: Currently, there is very little literature regarding PPRs. Additionally, very little research exists describing how ATs function within the ACA model of health care delivery. Description: The PPR developed a rotation for a rural FP outpatient clinic. Athletic training residents completed 3-week rotations in this setting working with multiple providers. Learning objectives were created to emphasize the evaluation, diagnosis, and management of general medical conditions. Objectives were assessed at the conclusion of the rotation. Finally, data were collected to evaluate the impact of athletic training residents in the ACA model of health care delivery. Clinical Advantage(s): The athletic training residents improved their clinical evaluation and diagnosis skills in a FP clinic through this educational opportunity. This rotation cultivated and fostered interdisciplinary education and interprofessional collaboration. Finally, the observational findings of this rotation revealed the impact of ATs appear to align with the objectives of the ACA health care model, supporting the use of ATs in this role. Conclusion(s): This rotation highlights an area of clinical practice future ATs could pursue. Accredited PPR programs must consider the evolution in health care delivery and the shift in athletic training education standards to develop strong PP programs.