Family Practice Residency Program 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.

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.

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

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.

P064: Coastal family practice residency: simulation curriculum needs assessment survey

Introduction/Innovation Concept: Medical simulation is becoming increasingly useful for healthcare education. Simulation-based crisis resource management (CRM) has been shown to produce improvements in skill acquisition, communication and team behaviors. Simulation has become a key component of most Family Practice (FP) residency programs and many programs are moving towards developing formal simulation curriculums. The Coastal FP Residency is a relatively new and unique program with a large emphasis on rural medicine. Graduates have gone on to practice in remote areas with less access to supports for critically ill patients. Therefore, an effective simulation curriculum, focused on Emergency Medicine, is of great importance to this program. Methods: To develop our curriculum, Kern’s framework for medical education was selected given its prior success in similar endeavors. The first step of this approach involves a needs assessment, which we accomplished in the form of an online survey. The questionnaire included pre-defined topics pertaining to the training needs of FP Residents destined for Rural Practice with respect to technical skills, CRM skills, specific medical conditions and categories of medical conditions. Classification of answers included multiple choice, 5-point Likert scales as well as an option for free-text answers. The survey was distributed to pre-identified participants including stakeholders/educators within the Coastal FP residency program as well as simulation education leads for FP residencies throughout British Columbia (BC). Current residents, as well as program graduates were also asked to complete the survey. Curriculum, Tool, or Material: The results of this survey were used to develop formal goals and objectives which were in turn used to write or adapt 24 cases for the curriculum. Cases from categories (e.g. Pediatrics) rated as “Extremely Important” on the Likert scale were included proportionally more in the curriculum. The cases were also designed to assess/practice a higher proportion of CRM elements considered important and to address commonly identified difficulties in resuscitation. Cases were developed, where possible, using local or national guidelines and are currently in the stage of peer review (by a minimum of two peers). Conclusion: The curriculum will be implemented in July 2017 and we will transition towards the evaluation phase. Our goal is to develop and distribute formalized needs assessments to rural FP residencies across BC so that they may develop dynamic, formal curriculums of their own.

Can Reflective Writing Reconcile ACGME Core Competencies with Daily Encounters in Medical Education? A Prospective, Randomized, Cross-over Pilot Study

Introduction Residency program directors are still exploring means to teach and evaluate ACGME core competencies. Finding simple means to reconcile ACGME core competencies with daily encounters offers a unique opportunity. Reflective writing through narratives may be the answer to simple and affordable means to achieve such goals. Methods To investigate the educational value of reflective writing, we conducted a prospective, randomized, cross-over pilot study among family practice residency program residents. The intervention group was introduced to the educational intervention. During the intervention, each narrative was analyzed by the authors, sentence by sentence, helping the learners spot ACGME core competencies. A week later, both groups were given five preselected narratives (test narratives) to analyze and identify what ACGME core competencies were reflected. A week later, the control group was subjected to the same intervention to comply with the cross-over design of the study. Data were then collected and a statistical analysis was completed. Results Nine learners were randomized into the control group and ten were randomized into the intervention group. Each learner analyzed ten sentences within the five test-narratives. The mean score for each learner across the ten sentences was calculated. The grand mean score for each group was calculated. The grand mean score for the control group was 58.75 (SD 13.4). The grand mean score for the intervention group was 69.90 (SD 15.8). Our one-tailed t test analysis showed no significant difference between the two groups (t = 1.647, df = 17, p = 0.057). Conclusion Our pilot study failed to show any statically significant improvement in the learners ability to reconcile the ACGME core competencies with their daily encounters using reflective writing. We identified several possibilities for the negative outcome. Sample size seems to be a major contributor. Further prospective randomized studies using larger sample sizes would be worthwhile to answer our research question.

What Qualities Define an Expert Family Doctor?

D o you remember your first day on the job after successfully completing your family practice residency program? Although you may have been excited to be a “real” doctor, you were likely to have been nervous as well. How many times during that first week as an attending physician did your mind seem to short circuit? Confidence does seem to improve over time, but at what point in your career would you really consider yourself an expert in family medicine? With each passing day, we, as family doctors, shape our unique styles and talents, which eventually attract patients through our doors. We are driven to provide compassionate, patient-centered, and evidence-based care designed to improve the lives of the families who seek our professional services. Family doctors must know a tremendous amount about diseases, disorders, and preventive care that affect all individuals, members of all religions, and people of both sexes, whether healthy or chronically ill. As family medicine specialists, we can care for > 90% of the patients who consult us, and we expeditiously direct care to other specialists when necessary. Yet, at what point in our careers do we actually become experts in family medicine? Does simply becoming board certified make us experts? Expertise in medicine is acquired through years of contact with patients who trust our guidance. Although we have many drugs for treating both acute illnesses and chronic diseases, our track record for curing disorders such as diabetes, hypertension, and coronary artery disease is dismal. Let someone walk through the doors with chlamydia urethritis, and we can …

Integrated Behavioral Care Training in Family Practice Residency: Opportunities and Challenges

The value of integrated behavioral care has been noted for many years, but there are few descriptions of integrated training of primary care physicians, prescribing psychologists, and psychological/behavioral specialists. The authors describe a family practice residency program that trains family medicine physicians, prescribing psychology practicum students, and pre-doctoral and post-doctoral behavioral health consultants. Barriers to training in integrated care are described and solutions offered. The unique clinical and teaching roles of licensed prescribing psychologists in primary care are described.

A pharmacy's journey toward the patient-centered medical home

To describe the integration of a clinic pharmacy with a patient-centered medical home (PCMH). Primary care clinic in Monroe, WA, from 1981 to January 2011. Pharmacists and physicians with a previous working relationship in a family practice residency program established colocated practices in 1981. In addition to traditional pharmacy services, collaborative practice agreements were developed and clinical pharmacy services expanded over time. Reimbursement challenges for clinical pharmacy services existed in the fee-for-service environment. The acquisition of the clinic and pharmacy by Providence Health and Services created a new financial alignment with additional opportunities for collaboration. An internally funded grant established a PCMH pilot that included pharmacist participation. PCMH pharmacists and the care provider team identified areas to improve physician and clinic efficiencies and to enhance patient care. Clinical pharmacy services expanded under the PCMH model. Pharmacist activities included value-added refill authorization services, coordinated patient visits with the PCMH pharmacist and physicians, medication therapy management, diabetes and anticoagulation services, hospital discharge medication reconciliation, and participation in the shared medical appointment. Clinical pharmacy services are woven into the PCMH fabric of this clinic. New pharmacists will be challenged and rewarded in this evolving health care model.

NPs Provide Person-Centered, Comprehensive Care

Marilyn W. Edmunds PhD, NP T here was a very provocative letter to the editor in the January/February 2010 issue of the American Academy of Family Practice’s Family Practice Management online journal (www.aafp.org/fpm). The letter was written in response to an article suggesting health care reform should be defined in terms of person-focused care rather than disease-focused care. The letter quickly drew the attention of nurse practitioners (NPs), one of whom passed it on to me. The letter, from Sanford J. Brown, MD, in Mendicino CA, said, “Family practice residency programs still train doctors along the disease-focused models, and they don’t teach them how to run an independent practice so they can have the time to do person-focused, comprehensive, and coordinated care. It is somewhat ironic that midlevel providers, who aren’t expected to see as many patients per hour as physicians, are better suited to handle these tasks.” While I see this letter as a backhanded compliment from someone who seems to understand what makes a difference in NP care, a basic assumption here is flawed. In many practices, past research demonstrates that NPs see just as many patients as physicians.1 It is not just a matter that we “take time” to do person-focused, comprehensive, and coordinated care; rather, being person-focused and comprehensive is what we do as NPs. It underlies our whole attitude, our whole approach to what questions we ask and how we ask them. So, we do different things in the time that we spend with the patient than many physicians do. It is true that the original conception of the role would be that NPs work alongside physicians, seeing less acutely ill patients and spending more time with them, providing teaching and counseling. But the reality of the health care system is that there is higher patient demand than there are providers to meet their needs, and no one has the luxury of long patient visits. In some settings, such as university hospital clinics, the sickest primary care patients have gravitated to the NP caseload because patients prefer to have continuity of care rather than seeing a new resident every 3 months. But even with the demands of needy primary care patients and the restrictions of time, NPs still provide as much person-focused and comprehensive care as they can. I realize I am going out on a limb when I make these claims. I’m from the old school, when NP faculty inculcated these role values and behaviors into their teaching. I hope that today’s NP faculty still demands this type of approach from their students, because if NPs don’t really practice in a person-focused, comprehensive manner, we aren’t really practicing any differently than the physicians.

A Retrospective Study on Infant Bed-Sharing in a Clinical Practice Population

In 2005 the American Academy of Pediatrics published new recommendations on infant sleep environment which advised against infants bed-sharing. A retrospective study was done to determine the prevalence of infant bed-sharing and its associations in a clinical practice. Demographic data were collected from 2,405 infants from a large family practice residency program, which included OB care, in Missouri between March 2002 and February 2008. Data were extracted from electronic medical records at the first four well-child visits: 1 month, 2-3 months, 4-5 months, and 6-8 months of age. Data analysis was performed using SPSS statistical software package, version 12.0 and 15.0 (SPSS, Inc, Chicago, Ill). At the first, second, third, and fourth well-child visit 19, 18, 12, and 11% of infants bed-shared with an adult. Bed-sharing was associated with an infant missing one or more well-child visits (first and third visits only), breastfeeding (first and second well-child visits only), and low SES. Stratified analysis by residence showed that over the 6-year study the decrease in the rate of bed-sharing, in the urban and non-urban areas, was statistically significant (P = 0.005, 0.04, respectively). Infants born 2006-2007 had a decreased rate of bed-sharing compared to infants born 2002-2005 (0.22, 0.30, respectively, P = 0.00). In light of the high rate of bed-sharing recorded at the first well-child visit, the researchers recommend an increased emphasis on safe sleeping education during the third trimester of pregnancy.

Challenges Associated with Physicians' Usage of Electronic Medical Records

Using the Theory of Planned Behavior, institutional and diffusion theories as theoretical foundations, this study investigates physicians’ attitudes towards and usage of electronic medical records (EMR). Interviews with seventeen physician-residents enrolled in a Family Practice residency program and eight attending physicians in the same clinic showed that most physicians held rather negative attitudes regarding the EMR system. EMR was often times seen as an intrusion in the patient-physician interaction. Other findings relate to how EMR impacts physicians’ time, expertise, and learning, as well as the length (and sometimes the accuracy) of clinical notes. Challenges associated with behavioral control issues such as availability of computers and the physical positioning of computers are shown to be very important in the context of this case. In this organization, physician-residents are required to use EMR because of its mandatory nature, however, if they had a choice or the power, the majority of them would use the paper chart.

Demystifying Abnormal ALP via Enzyme Evaluation

Margaret A. Fitzgerald is the President of Fitzgerald Health Education Associates, Inc., North Andover, MA, and Adjunct Faculty in the Family Practice Residency Program, Greater Lawrence (MA) Family Health Center.

The One-Minute Preceptor

The One-Minute Preceptor (OMP) is a teaching tool that has been used successfully for over 10 years in family practice residency programs. It was designed to enhance the teaching skills of physicians involved in the clinical education of new residents. This article describes the five steps of the OMP and how it was taught to a group of nurse preceptors and reports their evaluations of the impact that this education had on their ability to instruct and offer feedback to the novice nurse.

How Primary Care Kept Geriatrics

How Primary Care Kept Geriatrics

97: 12-Lead Electrocardiogram Interpretation Skills of Senior Medical Students Entering Emergency Medicine, Family Practice, and Internal Medicine Residency Training Programs

Electrocardiogram (ECG) interpretation is an important clinical skill for senior medical students (MS) entering emergency medicine (EM), family practice (FP), and internal medicine (IM) residency programs. Research shows senior MS have deficiencies in ECG interpretation and that these skills do not change over the final year of medical school. However, little information is available describing these skills among senior MS entering these programs. This study aims to describe how residency aspiration impacts ECG interpretation skills.

A National Survey of Terrorism Preparedness Training Among Pediatric, Family Practice, and Emergency Medicine Programs

Domestic terrorism is a real threat focusing on a need to engage in effective emergency preparedness planning and training. Front-line physicians are an important component of any emergency preparedness plan. Potential victims of an attack include children who have unique physiologic and psychological vulnerabilities in disasters. Front-line providers need to have adequate training to effectively participate in local planning initiatives and to recognize and treat casualties including children. The goal of the survey was to assess the current state of terrorism preparedness training, including child victims, by emergency medicine, family practice, and pediatric residency programs in the United States and to assess methods of training and barriers to establishing effective training. A survey was e-mailed to a comprehensive list of all US pediatric, family practice, and emergency medicine residency programs 3 times between September 2003 and January 2004. The survey measured the perceived risk of terrorist attack, level of training by type of attack, level of training regarding children, method of training, and barriers to training. Overall, 21% of programs responded (46 of 182 pediatric, 75 of 400 family practice, and 29 of 125 emergency medicine programs). Across all of the event types, emergency medicine programs were more likely to report adequate/comprehensive training. However, < 50% of emergency medicine programs report adequate training for children. Didactic classroom-based lectures were the most commonly used method of training. Emergency medicine programs were more likely to use scenario-based exercises. Among programs that use scenario exercises, 93% report that they never (40%) or only sometimes (53%) incorporate child victims into the scenarios. Time, funding, access to subject matter experts, and availability of training material are the most important barriers to effective training. Children are a precious national resource and a vulnerable population in disasters. Despite the availability of terrorism preparedness funding, these data suggest that we are failing to provide adequate training to front-line providers who may care for children in a catastrophic domestic terrorist event.

Aligning the Interests of Osteopathic and Allopathic Teachers of Family Medicine

“Integrating osteopathic training into family practice residencies has the potential of adding depth to any family practice residency program.”[1][1] “To survive as a unique medical entity, the osteopathic profession must curtail the ongoing exodus of young graduates from the philosophical

Developmental Dysplasia of the Hip: Definition, Recognition, and Prevention of Late Sequelae

When a child presents with a dislocated hip after the walking age, parents are upset, pediatricians are distraught, and lawsuits often follow. The prevention of late presentation is a goal that all practitioners should strive for. However, at this time, using current diagnostic techniques, the late presentation of DDH can be minimized but not eliminated. The AAP Subcommittee on DDH has estimated that approximately 15% of DDH at birth is not detectible, even by experienced examiners or ultrasonographers. In addition to preventing the late presentation of a developmentally dislocated hip, the prevention of premature degenerative arthritis of the hip secondary to developmental subluxation and acetabular dysplasia is equally, if not more, important in terms or morbidity and cost. It is hoped that the identification and treatment of babies with DDH at birth will have the added benefit of decreasing the incidence of degenerative arthritis of the hip in adults. As the key to early detection remains repeated, careful examination of the infant in the first year of life, it is imperative for practitioners to become as skilled as possible in performing the exam. Unfortunately, medical school curricula and pediatric and family practice residency programs often are deficient in teaching the neonatal hip examination. Strategies for clinicians to improve their examination technique include asking a pediatric orthopedic surgeon to demonstrate the examination in their nursery or attending one of the AAP courses on DDH. Starting a formal DDH screening program in the nursery is another option, using few screeners to maximize their experience. Nurse practitioners, physician's assistants, and physiotherapists could be used in addition to physicians. Having a child present with a developmentally dislocated hip after the walking age is not malpractice if the child has had repeated careful examinations. It is important to document the examinations in writing, rather than placing a check mark next to "musculoskeletal" or "hips" on standard, pre-printed exam forms. The best documentation is a handwritten note that states "the hips are stable and there is wide symmetrical abduction" at every well-child visit. At this time, careful, repeated physical exam supplemented by ultrasonography or X-rays for babies with risk factors is our best strategy to minimize the late presentation of DDH.

Challenges in vulnerable populations

The numbers are frightening—asthma affects approximately 21 million adults and 6.3 million children in this country. The lower the socioeconomic level, the higher the prevalence of asthma—and the higher the morbidity and mortality. Eric Madrid practices at Rancho Family Medical Group, Temecula, Calif. Greg Mennie and Patricia Newton are on the faculty of the Family Practice Residency Program, Presbyterian Intercommunity Hospital, Whittier, Calif, which is affiliated with the Department of Family Medicine, University of California, Irvine. The authors have indicated no relationships to disclose relating to the content of this article.