Family Practice Residency Research Articles

The development of resident "report cards" in the context of managed care education.

This article describes the development of residents' report cards as one component of a curriculum on physician profiling for primary care residents. Thirty-two first-year residents matriculating into family practice, internal medicine, pediatrics, and obstetrics-gynecology residency programs in 1998 were profiled. The patient information in the report cards was limited to data on a panel of Medicaid patients initially seen in the resident ambulatory care clinics. All subsequent patient care for that population was also included. The method was multi-step and complex, involving hospital billing personnel and cooperation with a managed care partner. A three-session educational program was developed to introduce the concept of physician profiling. The first session consisted of a panel discussion on managed care. The second session was devoted to a discussion of hypothetical physician profiles with inappropriate length of stays, days/1,000, low numbers of office visits combined with high urgent-care use, and high outpatient services utilization. Small groups of residents participated in a problem-identification process as if they were members of a group practice. Residents identified problems in the reports and made suggestions for behavioral changes. A final session presented residents with their own personal report cards. Residents were surveyed both at the beginning of their first year and before and after the educational intervention on profiling. Resident attitudes, which were negative toward managed care at the outset, became generally more positive. Comparisons of pre-test and post-test means on the five-point Likert scale, using a paired-samples t-test, revealed significant changes in the residents' attitudes overall.

House Calls

House Calls is the autobiography of one of the more famous founders of the specialty of family medicine, Dr. Thomas Stern. Dr. Stern's distinguished career included service as the residency director at one of the first family practice residencies in California. He was also the vice president for education and scientific affairs for the American Academy of Family Physicians. He became something of a celebrity, however, as a result of his role as the medical consultant for the Marcus Welby, M.D. television series. The book chronicles Stern's life—from the orphanage, to the military, to medical school, and then into practice. Much of the book is focused on his practice in rural Sherwood, Oregon. The story describes his beginnings in a private practice and reveals openly his self-doubt and worry as a young “country doctor.” As a “Generation One” family doctor, Stern had no formal postgraduate training in primary care, because family medicine had not yet been invented as a medical specialty. His teachers were, in the truest sense, his patients. It becomes clear as one reads the book that Dr. Stern cared deeply for his patients and what happened to them. He was not afraid to share with patients his true thoughts and feelings. For example, he tells a story of a patient who was an alcoholic in an abusive relationship. Stern recognized her reliance on alcohol and an abusive husband as a symptom of her low self-image. He used his therapeutic relationship with the patient to help her get past the denial she was in and see that she could have a better life. One is also struck with a sense of the sacrifice that Stern and his family undertook so that he could provide care for his patients at all hours of the day and night. Many times, patients would come to the back door of his home in need of stitches or an injection. His wife convinced him to construct an examination area on the back porch when she tired of his examining patients on the kitchen table. Overall, House Calls is a very moving story of a family doctor and his interactions with patients. Stern's life demonstrates commitment to the biopsychosocial model for continuous and comprehensive care for the entire family that is the hallmark of family practice. More broadly, his therapeutic approach serves as a worthy model for any primary care physician wishing to fully appreciate the psychosociospiritual needs of his or her patients.

Influence of a nutrition education program on therelated knowledge and behaviors of family practice residents

Influence of a nutrition education program on therelated knowledge and behaviors of family practice residents

Residency training in colposcopy: A survey of program directors in obstetrics and gynecology and family practice

Objective: Our goal was to identify how colposcopy is being taught to residents in obstetrics and gynecology and family practice programs and to see if the program directors think their residents receive sufficient clinical exposure to be adequately trained in colposcopy. Study Design: A 30-question survey was sent to all obstetrics and gynecology and family practice residency program directors. The survey included questions about the didactic nature of the colposcopy curriculum, the type of supervision, how resident skills are evaluated, estimates of the numbers and types of patients evaluated, the numbers and types of procedures being done by each resident, and the program director's perception of residents' competence in colposcopy. Results: The overall response rate was 485 of 752 program directors (64.5%). Significantly fewer family practice than obstetrics and gynecology program directors thought they had adequate numbers of colposcopy patients to train their residents. By their program directors' estimates, 86% of family practice residents evaluate 10 or fewer patients with high-grade lesions (versus 16.5% of obstetrics and gynecology residents); 51.4% evaluate 10 patients or fewer with low-grade lesions (versus 6.7% of obstetrics and gynecology residents), and 40.6% evaluate 10 patients or fewer with atypical squamous cells of undetermined significance (versus 3% of obstetrics and gynecology residents). Experience with vulvar disease is also limited. Program directors thought their residents' colposcopy skills were roughly comparable with their general obstetrics and gynecology skills. Conclusions: It is possible that many program directors underestimate the number of colposcopic examinations required to achieve and maintain colposcopic skills. Many training programs have insufficient clinical volume to properly train residents in colposcopy. (Am J Obstet Gynecol 2001;185:507-13.)

Psychosocial training in U.S. internal medicine and family practice residency programs.

Competence in the psychosocial aspects of medical care is necessary for primary care physicians to function effectively. This study investigated the psychosocial training internal medicine and family practice residents receive in U.S. programs. In 1996, program directors of all U.S. internal medicine (IM) and family practice (FP) residency programs were surveyed regarding the format, content, and quantity of psychosocial training provided in their programs, their opinions on topics related to psychosocial training, and demographics of their programs. The response rate was 61%. Ninety-nine percent of FP and 62% of IM program directors reported requiring at least one psychosocial training experience. Family practice programs required an average of 352 hours (SD +/- 175; range 27-2,664) of psychosocial training compared with 118 hours (SD +/- 272; range 0-1,050) for IM programs. Most IM and FP program directors expected residents to achieve at least basic competency in virtually all psychosocial topic areas; however, FP programs provided a greater range of psychosocial experiences. FP program directors most often identified psychologists and IM program directors most often identified internists as providing the most psychosocial training in their programs. Both IM and FP program directors considered lack of curricular time to be the main obstacle to development of psychosocial training. Residents' competence in psychosocial areas is important to both IM and FP program directors. However, content and time devoted to psychosocial training vary considerably both within and between program types.

The impact of Put Prevention into Practice on selected clinical preventive services in five Texas sites

Objective: To determine whether the implementation of the Put Prevention Into Practice (PPIP) office-based system would increase the delivery rates of specific clinical preventive services among demonstration clinics. Methods: Chart review was conducted before ( n=372) and 33 to 39 months after ( n=376) the implementation of the PPIP office-based system in two community health centers and three family practice residency programs in Texas. The population included all adult patients aged ≥19 years who had presented to the clinic during the study periods. Results: Documentation of timely cholesterol screening increased from 70% to 84%; smoking assessment, from 56% to 80%; for women, up-to-date Papanicolaou smear, from 70% to 81%; annual mammograms (women aged ≥51), from 30% to 48%; and up-to-date tetanus–diphtheria immunizations, from 19% to 59%. For adults aged ≥66 years, documentation of pneumococcal immunization increased from 22% to 48%, while influenza immunizations improved, although not significantly (45% to 49%). Blood pressure screening was almost universal (99%) at baseline and at 33- to 39-month follow-up. Conclusion: PPIP system changes were associated with an observed increase in delivery of selected clinical preventive services.

Sexual Abuse Knowledge Base Among Residents in Family Practice, Obstetrics/Gynecology, and Pediatrics

Study Objective: To investigate resident physician knowledge about sexual abuse prevalence and understanding about potential perpetrators. Design: Questionnaires were mailed to program directors in family practice, obstetrics and gynecology, and pediatric residency programs. Participants: The questionnaires were distributed to senior residents in their final months prior to graduation. Interventions: Residents were asked to fill out the questionnaire anonymously and return it to our institution in the prepaid envelope provided. Main Outcome Measures: Demographic characteristics and knowledge of sexual abuse prevalence and perpetrator characteristics were assessed. Chi-square contingency table analysis was used to compare responses of the three specialties. Results: The overwhelming majority (98.8%) of residents correctly identified a family member as the individual most likely to sexually abuse a child. Approximately half of the residents knew the correct prevalence of sexual abuse among females and among males. There was a weak understanding of the potential youthfulness of juvenile offenders. Conclusion: We believe that resident understanding of sexual abuse prevalence and about the youthfulness of juvenile offenders can be improved in all three specialties.

The role of problem-based learning in a new family practice residency curriculum.

The role of problem-based learning in a new family practice residency curriculum.

Head injury and alexithymia: implications for family practice care.

Alexithymia, a deficit in emotional information processing, and a history of head injury have both been found to be related to high rates of psychosomatic illness, substance abuse, depression, and utilization of primary care services. To date, no study has examined the potential comorbidity of alexithymia and head injury in a family practice setting, a necessary step in evaluating the aetiologic role of head injury in the development of alexithymia. The goals of this study are to establish prevalence of head injury and alexithymia in a family practice setting and to evaluate the relation, if present, between the two. Patients (n =135) of a family practice residency facility were screened using the Traumatic Brain Injury Questionnaire and the Toronto Alexithymia Scale-20. Forty-nine per cent of the participants reported a history of head injury and 18% were alexithymic. Those with a history of head injury had significantly higher scores of alexithymia. Chi-square analysis indicated a relation between head injury and alexithymia. The high rates of self-reported history of head injury in family practice settings, particularly in the context of alexithymia, may adversely affect a physician's ability to care for these patients. Increasing physicians' awareness of head injury and the potential mediating role of alexithymia in medical and psychological illness may facilitate effective diagnosis and patient-physician communication.

Untangling the Roots of Some IMGsʼ Poor Academic Performance

Untangling the Roots of Some IMGsʼ Poor Academic Performance

Does Analgesia or Anesthesia Make Colposcopy Less Painful

Colposcopy with cervical biopsy and endocervical curettage (ECC) is a common office gynecologic procedure; however, few guidelines address measures to reduce discomfort during this procedure. Previous investigations of nonsteroidal anti-inflammatory drugs and topical anesthesia have produced conflicting results regarding efficacy. In this study, based at a U.S. ambulatory teaching site for a family practice residency, 99 women (aged …

Teaching community health assessment skills in a problem-based format.

If physicians are able to understand the health status of populations they can use this understanding to develop targeted health care services for their patient populations or communities. Since 1991, the family practice residency program at the State University of New York Health Science Center at Brooklyn has taught community health assessment using a problem-based format. During this four-week rotation, residents gather, classify, and analyze demographic and health data about a specific local population. They use these data and published research literature to create rates that they believe will help to illuminate the health status and health issues of their community. By the end of the rotation, the residents feel comfortable working with rates and understand both their usefulness and their limitations. This rotation also introduces them to the concept of population health and some of the skills necessary to understanding a population-based approach to health care.

Head injury and alexithymia: implications for family practice care

Background: Alexithymia, a deficit in emotional information processing, and a history of head injury have both been found to be related to high rates of psychosomatic illness, substance abuse, depression, and utilization of primary care services. To date, no study has examined the potential comorbidity of alexithymia and head injury in a family practice setting, a necessary step in evaluating the aetiologic role of head injury in the development of alexithymia. The goals of this study are to establish prevalence of head injury and alexithymia in a family practice setting and to evaluate the relation, if present, between the two. Methods: Patients (n =135) of a family practice residency facility were screened using the Traumatic Brain Injury Questionnaire and the Toronto Alexithymia Scale-20. Results: Forty-nine per cent of the participants reported a history of head injury and 18% were alexithymic. Those with a history of head injury had significantly higher scores of alexithymia. Chi-square analysis indicated a relation between head injury and alexithymia. Conclusions: The high rates of self-reported history of head injury in family practice settings, particularly in the context of alexithymia, may adversely affect a physician's ability to care for these patients. Increasing physicians' awareness of head injury and the potential mediating role of alexithymia in medical and psychological illness may facilitate effective diagnosis and patient-physician communication.

Using the Analytic Hierarchy Process for the Selection of First-Year Family Practice Residents

Using the Analytic Hierarchy Process for the Selection of First-Year Family Practice Residents

Termination of a contract to implement an enterprise electronic medical record system.

The development of integrated health care systems, the building of distributed computer networks throughout them, and the advent of easy-to-use electronic medical records for ambulatory practices combine to create a powerful argument for an enterprise electronic medical record. Potential customers need to learn from both successes and failures. Although the author could find in the literature only two reports of failures, a survey of family practice residencies revealed ten programs in which use of an electronic medical record had been discontinued. The author reports on a project that was terminated even though the technology was adequate to achieve the original project goals.

Development and Implementation of a Geriatric Care/Case Management Program in a Military Community-Based Family Medicine Residency

This article discusses how the development of a longitudinal geriatric assessment form facilitated a case management program in identifying high-risk frail elders within a military family practice clinic. A careful review of geriatric assessment tools was performed. From this review, a model geriatric assessment form was developed. A "SWOT" (strengths, weaknesses, opportunities, and threats) analysis of the family medicine department was completed to determine if the environment was ready for case management. Analysis of the SWOT data revealed that the environment was favorable for a population-based approach to case management. Results of this initial study are encouraging. The new longitudinal geriatric assessment form has assisted family practice residents in organizing problems and data while seeing elderly patients. As a direct result, higher-risk frail elders have been identified for closer evaluation and follow-up. Future goals are to measure outcomes-based data and to refine the geriatric assessment process.

How long will you be staying, doctor?

How long will you be staying, doctor?

Validity of Residents' Self-Reported Cardiovascular Disease Prevention Activities: The Preventive Medicine Attitudes and Activities Questionnaire

Background. This article describes the development, reliability, and validity of three cardiovascular disease (CVD) prevention subscales—CVD prevention behaviors, perceived importance, and perceived effectiveness—of the Preventive Medicine Attitudes and Activities Questionnaire (PMAAQ).Methods. The PMAAQ was administered three times to University of Minnesota family practice residents (178) over 2 years (91% response rate). Stability measures were calculated, and validity was demonstrated in four ways: content validity through an expert panel; calculation of internal consistency reliabilities; demonstration of divergent validity; and external validation via a separate chart review.Results. High internal consistency reliabilities among the subscales were seen (Cronbach's α = 0.77 to 0.92). Divergent validity was verified by low intercorrelations among the subscales (r = −0.23 to 0.27). Two-month test–retest scores ranged from Cronbach's α = 0.47 to 0.64. Significant correlations were seen between the chart review scale and both the CVD behaviors subscale and the PMAAQ smoking scale (r = 0.25 and 0.36, respectively).Conclusions. Results indicate that the PMAAQ can validly and reliably measure residents' CVD prevention behaviors and provide insight into their preventive health care attitudes. Further, the independence among the subscales suggests that importance and effectiveness by themselves do not affect behavior and that other factors are likely to be important in influencing physician behavior change.

Collaborative Counselor and Medical Training at a Family Practice Residency Program: A Sharing of the Experience

There is growing interest in collaborative clinical work between physicians and counselors. The reactions of a Ph.D.-level, counselor-in-training, a medical student, and a family practice resident to collaborative systems clinical training at a family practice residency program are given in this article. The initial impressions of the teaching model, the impressions of the content and process of the model, the benefits and struggles with the model, and how the experience changed their views of behavioral science training are addressed in the responses.

Colorado family practice graduates' preparation for and practice of emergency medicine.

Family physicians provide care in emergency departments, especially in rural areas; however, no published data describe how they perceive their preparation for emergency practice. We surveyed graduates of Colorado family practice residencies concerning their emergency medicine practice, their comfort working in emergency departments, and their perceived preparation for practicing emergency medicine. Seventy recent graduates of Colorado residencies were surveyed regarding their location, work in emergency departments, contact with emergency medical services (EMS) personnel, and perceptions about their emergency medical training. Forty-five percent of respondents practiced in rural settings, 33% worked in emergency departments (56% rural, 14% urban), 60% reported contact with EMS personnel (91% rural, 32% urban), 54% believed their training adequately prepared them for working in emergency departments (82% rural vs 32% urban), 63% of rural and 22% of urban respondents indicated they wanted more major trauma experience during training, 70% reported discomfort with managing trauma, and 44% were interested in a 6-month emergency medicine fellowship. Most respondents believed their training in emergency medicine was adequate; however, most also reported discomfort with trauma management. Improved training for family physicians who provide emergency care could include expanded trauma care opportunities, increased work with EMS personnel, and postresidency training.