Family Practice Residency Program Research Articles

The process of resident selection: A view from the residency director's desk

In 1992, the Executive Council of the Association of American Medical Colleges recommended that a computerized application system be investigated. Under this system, the application package would include: 1) a standardized application form, 2) a personal statement, 3) a dean's letter, 4) transcripts, 5) a chairman's letter, and 6) United States Medical Licensing Examination (USMLE) scores. To investigate the value residency directors placed on these items, all directors from Accreditation Council for Graduate Medical Education--approved residency programs in obstetrics and gynecology and family practice residency programs were surveyed. The directors were asked to prioritize the usefulness of the proposed components of the Electronic Residency Application Service application package. Transcripts, the dean's letter, and USMLE scores ranked highest (in descending order) for the obstetrics and gynecology residency directors for making decisions about "inviting a student for an interview," whereas the dean's letter, personal statement, and transcripts ranked highest for the family practice residency directors. Both ranked the interview as most valuable in ranking a student in the residency match. Although these two disciplines do not represent all fields, our study indicates that residency programs are not homogeneous in their value systems and that certain characteristics may predict those values.

Physician office laboratory education and training in primary care residency programs

To assess the status of office laboratory residency education and training in family practice, internal medicine, obstetrics and gynecology, and pediatric residency programs. A single mailed survey to 1299 residency programs from December 1992 to February 1993. Primary care residency directors from 507 (39%) of 1299 programs. A 27-item survey of residency-based office laboratory practices, education, training, and resources. Differences between specialties in provision and quantity of office laboratory education and training, presence of a residency-based office laboratory, laboratory classification under the Clinical Laboratory Improvement Amendments, and available laboratory tests. Of those responding, office laboratories were present in 89% of family practice, 19% of internal medicine, 29% of obstetrics and gynecology, and 24% of pediatrics residency programs. Laboratory training was available at 60% of family practice, 16% of internal medicine, 15% of obstetrics and gynecology, and 30% of pediatrics programs. The median number of hours of formal skills training was 10 hours for family practice residency programs but less than 2 hours for the other specialties. Only 25% of the programs reported educational assistance from pathologists. Merely 4% of the programs had postassessment examinations and 2% awarded certificates of achievement. A majority of family practice programs performed waivered tests and physician-performed microscopy tests, but moderately complex tests were performed in less than 50% of family practice programs. Family practice residency programs provide more office laboratory training for residents than other specialties. There is a need for improved residency training in the basics of office laboratory practice.

Primary Care Physicians and Pain

This study examines whether family practice residents are receiving adequate training in the evaluation and treatment of pain during their residencies. A survey of the training directors of all family practice residency programs in the United States (n = 390) was conducted by mail. Questions were included regarding the residency programs and training in and knowledge of common pain conditions and therapies. Of all the training directors surveyed, 258 (66%) responded. The relationship between adequate training in pain and the characteristics of the residency programs was examined. Twenty-nine percent of the training directors who responded considered that their residents received adequate training in the recognition and treatment of pain. Adequate training correlated with rotation through pain services and the number of hours of lecture on pain provided. While the majority of program directors reported that their trainees were receiving training in many of the common pain syndromes and the use of analgesic medications, significantly fewer (p < 0.001) considered it to be adequate. Family practice training directors do not believe their residents are receiving adequate training in pain. In light of previous studies indicating the importance of providing proper pain treatment, enhanced teaching on this subject during residency appears to be needed.

Resident training in nursing home care: survey of successful educational strategies.

To identify educational strategies for resident training in nursing home care deemed successful by a large number of programs. A mail survey with three follow-up mailings. Directors of accredited internal medicine and family practice residency programs. Open- and closed-ended questionnaire eliciting curricular content, instructional strategies, and evaluation techniques from programs offering a nursing home experience. Identification of barriers to implementation of a nursing home curriculum and recommendations for success were requested. Of the 814 surveys mailed, 537 were returned for a response rate of 66%. Nursing home experiences were required in 86% of family practice residency programs but in only 25% of internal medicine programs. Most geriatric medicine curricular content areas were taught in the nursing home; however, relatively little emphasis was given to rehabilitation, organization, and financing of health care, and coordination of care between acute and chronic settings. Direct patient care, bedside rounds, and lectures were the most common instructional strategies reported. Evaluation approaches included faculty observations, resident attendance, and chart reviews with written and skill-based examinations infrequent. Availability of faculty and conflict with other rotations were identified as the principal barriers to implementation of nursing home rotations. An organized nursing home curriculum supervised by enthusiastic faculty using a longitudinal rotation format with resident involvement in an interdisciplinary team was recommended. Educational strategies exist for successful implementation of a residency nursing home curriculum. Greater priority must be given to training residents in nursing home care and developing nursing home faculty to substantially increase the number and quality of physicians who practice in this setting.

Retention Rates and Retention Predictors among Graduates of Army Family Practice Residency Programs

Accurate career retention rates for the 688 graduates of Army Family Practice residency programs over the period from 1973-1990 were determined by retrospective cohort analysis. Eight characteristics of these graduates were tested by chi-square analysis to determine if they had a predictive effect on retention: United States Military Academy attendance (USMA), Uniform Services University of the Health Science (USUHS) attendance, fellowship training, prior service, gender, first assignment, site of residency training, and spouse with history of active duty service. Overall retention was 21%. Significant predictors of retention at the p < 0.01 level (chi-square) were (1) USMA attendance, (2) USUHS attendance, (3) fellowship training, and (4) prior service. Gender, first assignment, and spouse history of active duty service were not factors. The 22% of the graduates who had at least one of the four positive predictors form two-thirds of the present career Family Physician force.

The Larimer County Children's Clinic. A public-private partnership to provide medical care to indigent children.

To describe a unique collaboration between private and public entities to provide comprehensive health care to medically indigent children in rural Larimer County, Colo. The Children's Clinic, Fort Collins, Colo. Uninsured children and those eligible for Medicaid, living in families with incomes below 150% of the federal poverty level. Eligible patients have been enrolled in the Children's Clinic on a first-come, first-served basis. A community collaboration involving an interactive system with the Children's Clinic staff, the Larimer County Department of Health and Environment, private primary care and subspecialty physicians, ancillary health providers, and the family practice residency program at Poudre Valley Hospital, Fort Collins. Funding for this endeavor has been composed of city and county funds, public and private grants, community business support, and local fund-raising efforts, as well as Medicaid reimbursements. Since 1989, comprehensive pediatric care has been provided to a growing number of eligible children. At present, 3619 children, aged birth to 18 years, from 2230 families are being served. From this population, there were 8945 office visits to the Children's Clinic, 1392 patient contacts by the clinic social workers, 1287 visits to the Larimer County Department of Health and Environment for well-child care, 543 referrals to subspecialists and other community health care providers, and 615 after-hours visits to the Poudre Valley Hospital emergency department between July 1, 1992, and June 30, 1993. The clinic's professional staff consists of 2 1/4 full-time pediatric care providers, one nurse, one medical social worker, one receptionist, and one administrator, with an expenditure of $356,471. The Children's Clinic collaboration has provided comprehensive pediatric health care to a population that previously received only fragmented care. The next step is to assess the impact of this program on the frequency of emergency department visits for these patients.

Training in obstetric sonography in family medicine residency programs: results of a nationwide survey and suggestions for a teaching strategy.

Obstetric sonography is a valuable diagnostic procedure for family physicians who provide obstetrics; however, physicians tend to use technology that was effectively modeled during residency. The purpose of this study was to learn how many family medicine residency program directors had an interest in and a need for training in obstetric sonography, as well as whether they were willing to commit faculty and finances for adding the technology to their programs. All program directors listed in the 1989 American Academy of Family Physicians (AAFP) Directory of Family Practice Residency Programs (n = 379) received a five-item questionnaire about obstetric services and use of sonograms in their programs and their desire for training in obstetric sonography. More than 81 percent of respondents said their programs provided obstetrics. Sixty-eight percent of these respondents used sonograms, and 53 percent indicated a need for training in obstetric sonography. Forty-five percent of all respondents, regardless of whether their programs offered obstetrics, indicated a desire for training. The high level of interest in obstetric sonography can be explained, in part, by the 81 percent of respondents whose programs provided obstetrics. These figures suggest a need to establish a training curriculum in obstetric sonography for family medicine residency programs. Our training program, designed to reach faculty, residents, and practicing physicians, is described.

A strategy to increase the number of urban family practice resident physicians who enter rural practice.

Physician geographic maldistribution is a problem in the United States health care system. Innovative strategies are needed to entice resident family physicians training in the larger, more numerous suburban and urban training programs to practice in rural areas upon completing their training. This paper describes a strategy used at St. Elizabeth Medical Center Family Practice Residency Program, Dayton, OH, to encourage rural practice. In the St. Elizabeth plan, the interested family practice resident moonlights in a rural practice provided by the local county hospital. The county medical staff covers the resident physician's practice during the frequent absences. The residency program faculty provide on-site supervision, telephone back-up coverage, and practice consultation. The county hospital provides billing services; the resident physician retains 100 percent of collections. The resident physician gains exposure to the knowledge, skills, and attitudes needed in rural practice. Upon completion of residency training, the physician remains in practice and is not required to pay back any expenses incurred by the hospital. Two resident physicians participate currently; three others have expressed interest in practicing in the community. A similar plan might work in parts of the United States where, like Ohio, training programs and rural communities are not far apart.

Residency directorsʼ responses to the concept of a proposed electronic residency application service

In 1992, the Executive Council of the Association of American Medical Colleges (AAMC) recommended that the feasibility of the proposed Electronic Residency Application Service (ERAS) be investigated. This action was based on concerns that the current system was inefficient, costly, and disruptive to students, medical schools, and residency programs. The purpose of this study was to explore residency directors' opinions about the benefits and barriers to the introduction of such a system. All directors from family practice and obstetrics-gynecology residency programs were surveyed in early 1993. Three forced-choice and three open-ended questions elicited opinions concerning benefits and potential barriers to the implementation of ERAS. T-tests and chi-square tests for independence were used to examine differences for continuous and categorical variables. Overall, 544 residency directors (81%) responded to the questionnaire: 339 (86%) in family practice, and 205 (75%) in obstetrics-gynecology. Eighty percent of the respondents in family practice and 75% of those in obstetrics-gynecology were in favor of the initiation of ERAS. Perceived benefits included increased "efficiency," "simplicity," "standardization," and "completeness." Concerns included "technical problems," "loss of flexibility," "lack of a personal touch," "costs," and "lack of security." It is appropriate for the AAMC to take the lead in investigating the computerization of this important process. It is essential, however, to gather data from all three consumers of this potentially valuable service as an important step in the project's development.

Family practice residents' decision making regarding future practice of obstetrics.

This study assesses the attitudes of family practice residents toward their future practice of obstetrics. The decline of family practice obstetrics has resulted in problems of access to care for many areas. Questionnaires were sent to 30 family practice residency programs and were distributed to 353 2nd- and 3rd-year residents; the overall response rate was 85 percent. Respondents were asked to describe factors contributing to their decision whether to practice obstetrics. Seventy-two percent of the respondents indicated plans for future obstetrics practice. Reasons for choosing to practice obstetrics included personal interest, believing that obstetrics is an important part of family health care, and desire for diversity in practice. Primary concerns included interference with personal life, fear of lawsuits, and insurance premiums. Those deciding not to practice obstetrics cited interference with personal or professional life and desire for limited practice as deterrents. Important demographic variables predicting future practice included female sex, geographic location, and type of practice desired. This study portrays a resurgence in the percentage of family practice residents planning to practice obstetrics and discusses aspects of the training system that merit support to increase the number of family physicians providing obstetric care.

Influence of curricular changes in health promotion and disease prevention on residents' behaviors over a five-year period.

Residents' compliance with guidelines for health promotion and disease prevention (HPDP) often fall short of the ideal. After a year in which faculty developed clinical practice HPDP guidelines, an intervention consisting of curricular changes and chart modifications was planned and pilot-tested in 1985-86 at an ambulatory care clinic of the Family Practice Residency Program, University of Louisville School of Medicine. Approximately 24 residents per year (eight at each level of training) worked in the clinic throughout the study years. The HPDP curriculum required residents to attend 48 one-hour conferences conducted over a three-year period. Four retrospective chart audits were used to measure residents' compliance with the HPDP guidelines during (1) the year before the pilot test (104 charts), (2) the pilot year (113 charts), (3) the year after the pilot test--the first year of full implementation (100 charts), and (4) five years after the pilot test (100 charts). Data from the chart audits were analyzed by using a permutation test for decreasing trend. Although there was an increase in the residents' compliance with the HPDP guidelines during the pilot year, the residents' HPDP activities tended to return to baseline levels in the following years, despite the ongoing curriculum. The authors conclude that because the frequency of the residents' HPDP activities tended to return to baseline levels, clinical education alone is not enough to sustain residents' compliance with HPDP guidelines.

Nutrition knowledge and practices of physicians in a family-practice residency program: the effect of an education program provided by a physician nutrition specialist

The purpose of this study was to determine the effects of a nutrition-education program provided by a physician nutrition specialist in a family-practice residency program on residents' and faculty members' nutrition knowledge and nutrition-related patient care, their patients' perceptions of the importance of nutrition, and the physicians' dietary patterns. The nutrition specialist provided recommendations for nutrition patient-care practices to the physicians for 6 mo. Pre- and post-intervention assessments included 1) nutrition exams for physicians and patients, 2) patient questionnaires concerning attitudes towards nutrition, 3) chart reviews, and 4) diet records for physicians. The educational intervention caused a small but statistically significant (P < 0.01) increase in physicians' nutrition-knowledge scores and a significantly higher (P < 0.05) frequency of physicians discussing nutrition and recommending diets for their patients. Effects were greater among residents than among faculty members. The results suggest that a physician nutrition specialist can provide effective nutrition education within a residency program.

Controversies in nutrition

Associate Professor of Family Practice University of Wyoming, Family Practice Residency Program Cheyenne, Wyoming Assistant Director of Medical Affairs Mercy Medical Center Family Medicine, Residency Denver, Colorado

Exercise stress test training in family practice residency programs.

EST is a commonly indicated procedure in primary care medicine and as such is well suited for use by family physicians. At present there are few family physicians performing this procedure in their offices. Our survey of US family practice residency directors has shown an interest well above what would be expected for the level of current practice in the community; however, there remains an ambivalence on the need to provide EST training in the curriculum.

Liver function test abnormalities in early Lyme disease

Lyme disease is a widespread, tick-borne, spirochetal infection with multiple organ system involvement Hepatic dysfunction has not been emphasized in the literature. We report clinical findings and laboratory abnormalities in 73 patients with the pathognomonic erythema migrans rash early in the course of the illness. Case series. Offices of family physicians in private practice and the model offices of a family practice residency program in the lower Connecticut River valley, an area to which Lyme disease is endemic. Thirty-seven female and 36 male patients with erythema migrans who had not yet been treated with antimicrobial agents. Liver function tests. Twenty patients (27%) had liver function abnormalities. Elevation of gamma-glutamyltransferase was the most common finding. Only seven patients (9%) had a positive titer in response to the enzyme-linked immunosorbent assay for Lyme disease. Other laboratory and clinical findings are described. Subclinical hepatitis is a common finding in early Lyme disease.

An Educational Report: The Mechanics of Geriatric Assessment in a Military Community-Based Family Practice Residency

Over the past several years, increasing emphasis has been placed on geriatric training in family practice residency programs. Because geriatric assessment is an important educational concept, we elected to start an inpatient geriatric assessment program at our community-based military family practice residency. Our experience is outlined here.

Trends in the teaching of neurology to family practice residents, 1981-1990.

A decade ago, less than one-half of the family practice (FP) residency programs surveyed provided a defined rotation in neurology. To learn how neurology is currently being taught in FP residencies, we sent questionnaires to 384 approved FP residencies in the United States, receiving responses from 241 (63%). Seventy-eight percent provide a defined rotation in neurology, usually in the form of a preceptorship with a community neurologist, and 57% systematically present the core curriculum recommended by the American Academy of Neurology and the American Academy of Family Physicians in 1987. Asked about the level of cooperation they encounter in recruiting neurologists to teach, 54% of the respondents reported "too little" or "no" cooperation from academic neurologists, while just 20% reported these responses in regard to community neurologists. Most (87%) reported that involvement in the residency program leads to increased patient referrals for the participating neurologist. Most (81%) respondents would welcome more participation by neurologists.

Colposcopy practice and training in family practice residency programs.

The potential growth of colposcopy as a family medicine procedural skill is directly related to the training currently offered to family practice residents. To define whether these skills are being adequately offered to physicians who want to perform this procedure for their patients, a study was designed to investigate the current status of colposcopy practice and training in family practice residency programs. A 16-item survey sent to 356 family practice residency directors in the United States included items concerning colposcopy practice, training, educational programs and strategies, colposcopy coordinator educational background, and colposcopic resource materials and equipment. Surveys were returned from 204 (57 percent) family practice residencies. Colposcopy was performed at 45 percent of the residencies that responded. Ninety-six percent of the respondents who did not perform colposcopy believed colposcopy is a procedure that should be performed by family physicians. Clinical teaching and supervision was the most common method of resident training (74 percent). Colposcopy training coordinators were usually family physicians (72 percent), primarily trained by gynecologists. Assistance with implementing a colposcopy training program was requested by 85 percent of those programs presently not performing colposcopy. This study indicates that there are opportunities for further development of colposcopy practice and training in family practice residencies.

Impact of a simple reminder on documentation of pediatric health screening procedures.

Improvement in health screening and health maintenance has become a major issue in the assessment of high-quality medical care in recent years. A number of studies have delineated the standards of quality for documenting health maintenance, such as mammography screening and care of the hypertensive patient.1-10 Trends toward improvement in quality in ambulatory care are evident nationally and locally. The Joint Commission on Accreditation of Hospitals publishes a manual on the standards for ambulatory health care and is applying these standards to outpatient office practices. I I Institutions, such as the University of Chicago Hospitals, have developed quality assurance systems designed to be used in their ambulatory care clinics. 12 One area of emphasis in ambulatory family medicine training is well-child care. To this end, the American Board of Family Practice publishes a reference guide that serves as the standard of care for early disease detection during the wellchild visit. 13 Adherence to published standards of the well-child examination in a family practice residency program has not been reported in the current literature. This study was designed to improve physician compliance with routine well-child care by implementing a simple physician reminder system. A record review before and after implementation of the reminder was used to measure the impact of the intervention. The site selected for this project was the model Family Practice Center at Akron City Hospital, Akron, OH. A resident chart audit undertaken 1 year before this study indicated that although residents had almost always documented a cornea eye and tympanic

Residency education in the nursing home: a national survey of internal medicine and family practice programs.

To assess the role of the nursing home in postgraduate medical education. A survey questionnaire addressing the following issues: 1) prevalence of nursing home rotations in internal medicine and family practice residency programs, 2) duration and type of rotation, 3) extent of residents' responsibilities, 4) patterns of faculty supervision, 5) program directors' assessments of nursing home experience, and 6) frequently encountered problems. Directors of accredited internal medicine and family practice residency programs in the United States. A total of 502 surveys were returned for a response rate of 60%. Nursing home rotations were more frequent in family practice programs (87%) compared with internal medicine programs (32%). Rotations in internal medicine were generally optional and limited to a short block of time compared with family practice, where rotations were most often required and longitudinal. Internal medicine residents received more intense supervision, whereas family practice residents had greater clinical responsibilities. Few faculty had formal geriatric training or certification. Reimbursement for physician services was low. Although availability of faculty, resident interest, and conflict with other clinical services were identified as problem areas, program directors in both internal medicine and family practice were supportive of nursing home rotations for their trainees.