Family Practice Residency Research Articles

Cultural competency training in a new-start rural/frontier family practice residency: a cultural immersion integrated model.

Cultural competency training in a new-start rural/frontier family practice residency: a cultural immersion integrated model.

Investment in a rural residency program: a case study.

Rural hospitals have used numerous strategies over the past several decades to recruit and retain physicians. These have included providing physicians economic incentives, immigration status, professional and technical support and establishing rural training tracks (RTT) in family practice residency programs. This paper presents the experience of an isolated rural region in southwestern New York state that has employed each of these strategies in the past decade. Success as measured by the change in size of the medical staff, hospital operating margins, admissions and employment occurred only after the emphasis changed from meeting hospital needs to physician needs. Pivotal to this strategy was the nurturing and development of an RTT. Investment in the residency program required strong leadership to ensure the political, financial and operational commitment of its affiliated hospital. In addition, the RTT required an affiliation with a financially viable, full-service hospital, a strong on-site chief of service, family physicians who performed cesarean sections, midlevel providers and practitioners dedicated to the mission of teaching.

Rural health experience for urban family practice residents.

The Journal of Rural HealthVolume 16, Issue 3 p. 297-298 Rural Health Experience for Urban Family Practice Residents Jerome C. Andres M.D., Jerome C. Andres M.D.Search for more papers by this authorDon McLean M.S., M.A., Corresponding Author Don McLean M.S., M.A. Hamilton B. Mizer Primary Care Center, Niagra Falls, NY 14301; e-mail don.mclean@nfmmc.org.Search for more papers by this author Jerome C. Andres M.D., Jerome C. Andres M.D.Search for more papers by this authorDon McLean M.S., M.A., Corresponding Author Don McLean M.S., M.A. Hamilton B. Mizer Primary Care Center, Niagra Falls, NY 14301; e-mail don.mclean@nfmmc.org.Search for more papers by this author First published: 08 April 2008 https://doi.org/10.1111/j.1748-0361.2000.tb00477.xAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume16, Issue3June 2000Pages 297-298 RelatedInformation

Crafting an affiliation agreement: academic-community collaboration in a rural track family practice residency program.

Crafting an affiliation agreement: academic-community collaboration in a rural track family practice residency program.

Faculty support is essential for success

Residents in primary care training programs are increasingly required by the Accreditation Council for Graduate Medical Education to have experience in community medicine.1 The Family Practice Program Requirements state that residents in family practice must be taught to assess and understand the important health needs of the community in which they work.1 Internal medicine similarly requires service to that community as an important part of professionalism, and residents are encouraged to participate in community programs. Pediatric curriculums include community-oriented care involving the care of children in underserved groups, with attention to the multicultural dimensions of health care. The Tavistock Group—a multidisciplinary group of health professionals who met in Tavistock Square in London in 1991—recently issued a policy statement for those who shape and give health care.2 One of their five tenets states that cooperation with each other and those served is imperative for those working in the health care delivery system. In a recent treatise on innovative thinking for the improvement of medical systems, Plsek theorizes that the tools of idea generation are based on three principles: mental attention, escape, and movement.3 These are activities that help people to look at their current situations in a different way, to escape the way they usually think about things, and to support them in generating innovative, testable ideas to improve health care systems.3 The article by Miller and colleagues shows that a community needs assessment conducted by the community itself led to the development of a truly innovative project that at first blush would not have appeared to improve the health of the community. But, as the authors indicated, economic conditions and hygiene are often more important determinants of health outcomes than traditional medical or public health interventions. Besides allocated time and didactic teaching of community organizing and cultural competency issues, a critical element for the success of projects such as this is faculty commitment. Faculty must be willing not only to support the effort but also to engage in the activity itself or in similar endeavors and to thereby serve as role models to convince residents that this type of work is worthwhile. In Los Angeles, the Venice Family Clinic and Los Angeles Free Clinic serve as community service placement sites for residents in family practice, internal medicine, pediatrics, and obstetrics and gynecology from the University of California at Los Angeles (UCLA), UCLA-Santa Monica, Cedars-Sinai, and Kaiser Permanente medical centers. The success of these partnerships reflects the level of faculty commitment and involvement. The hope is that residents who are involved in such projects will develop an ongoing commitment to community service.

Enhancing influenza immunization. Postcard and telephone reminders and the challenge of immunization site shift.

To determine if postcard and telephone reminders increased the rate of influenza immunization of Medicare beneficiaries. Before and after trial (postcard reminders) with systematically allocated control group (telephone reminder intervention). A semirural family practice residency program. All 475 noninstitutionalized persons older than 65 years who had received at least 1 office service in the previous 2 years. In September 1996, each of 475 patients received a postcard urging prompt influenza immunization. Those not responding within 1 month were systematically allocated either to a group receiving further telephone contact or to a control group. At the time of telephone contact, any offered information about influenza immunization received outside the Smoky Hill Family Practice Center, Salina, Kan, was recorded. We measured the percentage of change in practice-administered influenza immunizations compared with the baseline rate of the preceding 2 years; the difference in immunization rates between the telephone intervention group and controls; and the number of patients contacted by telephone who reported receiving influenza immunization at a site other than the Family Practice Center. Twenty-eight percent of patients who received a postcard obtained office influenza immunizations within 1 month, but no additional immunizations could be attributed to the telephone intervention. Thirty-five percent of patients contacted by telephone reported receiving influenza immunization at a site other than the Family Practice Center. The postcard intervention was associated with a significant increase in the office immunization rate. This increase may have been confounded by "site shift" in which individuals came to the office for an immunization that they might otherwise have received at other community sites.

Physician awareness of domestic violence: does continuing medical education have an impact?

One hundred currently practicing physicians were surveyed regarding screening and management of domestic violence to determine whether mandatory continuing medical education (CME) is likely to increase awareness of and response to domestic violence. The authors surveyed 25 family physicians and 25 obstetrician/gynecologists in each of two states, Florida and New Jersey. In addition, they polled 26 family practice residents in the University of Medicine and Dentistry of New Jersey-School of Osteopathic Medicine program. Practices with a female physician were four times more likely to screen for domestic violence than practices with all male physicians. No difference existed in screening between family physicians and obstetrician/gynecologists; physicians in Florida and those in New Jersey; or attending physicians and family practice residents. Findings indicate that Florida's mandatory CME law does not appear to have made an impact on the management of domestic violence. Practices with a female physician were more likely to screen for domestic violence.

FACTORS INFLUENCING THE DECISION TO ENTER A GERIATRIC FELLOWSHIP PROGRAM

The ''specialty'' of geriatrics is not a popular choice for graduates of internal medicine and family practice residencies. The purpose of this study is to investigate factors that influence the decision of a primary care physician to enroll in a fellowship program in geriatrics. A questionnaire was mailed to all practicing primary care physicians (N = 1,011) in the state of Arizona (n = 1,011). Of the 1,011 physicians who were mailed questionnaires, 737 physicians returned the questionnaires for a response rate of 72.9%. Of these respondents, 242 (32.8%) stated they would consider entering a geriatric fellowship. The likelihood of entering a fellowship is strongly influenced by the duration of the fellowship with 81.8% rating the importance of the length of the fellowship. It is clear that recruiting fellows to enter a geriatric fellowship is difficult. The survey revealed that the length of the fellowship is an important factor in affecting the decision to enter such a fellowship in addition to the need for multiple track to geriatric medicine. The study sheds light on some factors which influence the decision to enter a geriatric fellowship. These factors need to be targeted, in any event, to improve the number of applicants in the future.

Smokers over age 35 continue to receive oral contraceptives: Survey of patients in a family practice residency practice

Objective - To assess the frequency with which women over age 35 report both current oral contraceptive use and current cigarette smoking. Design - Cross-sectional survey of women in a single practice setting. Setting - Primary care teaching practice in a mid-sized US city. Patients - 142 women aged 35-55 who had not reached menopause and had not had hysterectomy. Main outcome measures - Smoking status in current oral contraceptive users. Results - 19 women (13%) were current oral contraceptive users and 46 (32%) were current smokers. Four of the oral contraceptive users (21%) reported current smoking. Conclusions - Despite reported cardiovascular risk, women who smoke continue to receive prescriptions for oral contraceptives. Physicians should redouble efforts to record smoking status and offer smoking cessation treatment to women over age 35 who smoke and wish to take oral contraceptives.

Adult medicine training experiences in a small-town family practice residency.

To document the adult medicine experiences of family practice residents training in a small rural hospital. The authors tracked all inpatient admissions and consults for the first year of a newly accredited family practice residency program, located in a small-town, 80-bed hospital. They analyzed the data for volume of admissions, sources of admissions, diagnoses, lengths of stay, and ICU experience. The residents saw a significant volume of patients, encountered a wide variety of diagnoses, and had ample opportunities for learning, in spite of the small number of occupied beds. Family practice residents in small hospitals can have sufficient inpatient training experiences in adult medicine. The authors believe that the Accreditation Council for Graduate Medical Education should encourage the development of residency programs in rural communities by simplifying the accreditation documentation requirements for smaller hospitals.

Assessing the need for faculty development in women's health among internal medicine and family practice teaching faculty. The Women's Health Education Working Group (WHEWG).

Women's health education is an emerging interdisciplinary field that has recently received national attention. The American Board of Internal Medicine and the American Academy of Family Practice recently have published competencies in women's health for their residents, with increased attention to gynecological and mental health issues. Increasing women's health in the curricula of internal medicine (IM) and family practice (FP) residents will certainly require faculty development among IM and FP teaching faculty. We report a multiinstitution needs assessment among IM and FP teaching faculty for continuing medical education (CME) in multidisciplinary women's health topics. The survey (n = 100) asked whether faculty desired CME in 30 women's health topics. It also requested rates of referral to specialists for breast and menstrual problems and performance of tests commonly carried out in the care of women (e.g., endometrial biopsy, colposcopy, skin biopsy, and sigmoidoscopy) as measures of possible need for CME. Of the 69 respondents, 37% were IM physicians and 63% were FP physicians. Among the 30 women's health topics listed, breast cancer treatment alternatives, infertility for primary care providers, cervical dysplasia, medical treatment in pregnancy, vulvar disease, indications for pelvic ultrasound/endometrial biopsy, and menstrual disorders were of highest interest. The ranking of desirability of topics by IM and FP faculty correlated by .54 (Spearman rank, df = 28, p < 0.01). Analysis of variance revealed a significantly higher interest overall by IM than FP physicians, 58% vs. 42% (F = 4.1, df = 1, 50, p < 0.05). None of the IM teaching faculty performed endometrial biopsy or colposcopy compared with 57% of FP physicians, and only 12.5% of internists performed skin biopsy and sigmoidoscopy compared with 70% of FP physicians (F = 33, df = 1, 38, p < 0.001). We conclude that faculty development in women's health would benefit resident training in IM and FP, and topics of interest are identifiable. The correlation in interests between the IM and FP teaching faculty might make joint programs successful, although gynecological skills and knowledge clearly are needed more by IM teaching faculty. Obstetrics and gynecology (OB/GYN) faculty could be instrumental in improving women's health education among their IM and FP colleagues.

Teaching information mastery: creating informed consumers of medical information.

The concepts of evidence-based medicine are permeating all specialties, including family practice. This article describes a curriculum to teach residents the principles and practices of information mastery, a derivation of evidence-based medicine that is more relevant to family physicians. The curriculum is a 2-year longitudinal experience consisting mainly of didactic presentations and demonstrations in the first year followed by small-group sessions in the second year. Residents are taught the concepts of the previously described approach of information mastery and the application of these concepts to the variety of information resources available to them. Specifically, residents are taught how to find, evaluate, and apply information available from original research literature, review articles, meta-analyses, translation (controlled-circulation) journals, continuing education lectures, experts and colleagues, pharmaceutical representatives, and clinical experience. Using a before-after design at two institutions, the curriculum improved residents' attitudes, confidence regarding the medical literature, their perceptions of their ability to evaluate the published literature, and their use of information sources. Offering a structured curriculum to family practice residents creates dynamic, confident, and independent clinicians skilled in the art of information mastery.

The Great Canadian Rural Obstetrician Meltdown

Fewer and fewer family physicians are delivering babies in rural Canada. Due to a serious shortage of obstetricians, general surgeons and rural physicians with advanced operative skills, some community hospitals have been forced to discontinue these operative services. In some instances, they have been obliged to close their maternity units entirely. Women must then deliver far from home in unfamiliar regional facilities. Two solutions to this provider access crisis have been suggested.It has been proposed that certain rural physicians be trained in advanced operative obstetric skills (chiefly the performance of Caesarean sections) for those community hospitals which require these skills. Candidates for a programme of this sort would be drawn from graduating family practice residents and from the ranks of practising rural physicians returning for reinforcement of this operative experience. This emerging initiative raises important questions about training, the scope of practice, specialist backup and maintenance of competence.An alternative remedy would stress much broader exposure to obstetrics in family practice residencies, the opportunity for additional training in more advanced skills, rural practice experience for senior residents in obstetrics and gynaecology, equitable alternative funding for consultant obstetricians in regional facilities and considerable strengthening of regional links for perinatal care delivery.The short-and long-term consequences of this crisis must not be underestimated by the profession, by regional health boards and particularly not by government.

Caring for adults with mental retardation: survey of family practice residency program directors.

In their core curriculum guidelines, the Society of Teachers of Family Medicine has recognized the importance of training family physicians in caring for persons with mental retardation. We mailed surveys to all family practice residency directors in the United States, questioning them about experiences and methods used to teach residents about health care needs of adults with mental retardation and the importance of this education. We found that 84% of programs provide residents with one or more experiences, and 60% instruct residents in this area. Most directors ranked this education as very important or important. There was no relationship between type or age of residency program and likelihood that residents were educated about mental retardation. The importance of this education is discussed.

Training family practice residents in psychiatry: an ambulatory care training model.

To demonstrate the importance of providing psychiatric training to primary care practitioners in ambulatory care settings. Additionally, to describe the model used for this purpose in the Department of Psychiatry and Behavioral Sciences of the University of Texas Medical School at Houston in order to further stimulate educational opportunities on this topic. A review of the psychiatric curriculum offered to family practice residents during their PGY-2 year one-month rotation in psychiatry at the University of Texas Mental Sciences Institute is provided. Emphasis is given to key areas of the curriculum such as: knowledge, skills, and attitude development. Special focus on the clinical and educational experiences is also offered for the purpose of providing unique perspectives about the curriculum methodology. The careful assessment of the feedback obtained from the family practice residents who were exposed to this ambulatory training model demonstrates that this type of setting was satisfactory for the teaching of psychiatry to primary care residents. Primary care residents have always treated a large number of psychiatric patients. Given the current status of our health care system, primary care practitioners should have even a greater role in the future delivery of psychiatric services. In this article, we offer a model of training for primary care residents in psychiatry, which emphasize cost-effectiveness, high quality of care, and ambulatory care settings.

Breastfeeding Intervention: Targeting the Physician and the Clinic

Studies confirm that a comprehensive office-based system is necessary to support physicians and clinic staff in their efforts to routinely provide patient education aimed at behavior change. We assisted a family practice clinic in designing a system to promote breastfeeding (BF): routinely assessing all prenatal patients about BF knowledge/concerns; establishing standardized methods of counseling and patient chart documentation, using reminder systems; providing educational self-help materials; and planning follow-up activities. A Breastfeeding Promotion Team-a clinic physician and health educator-take leadership for implementing/maintaining the new BF program. A half-day clinic-wide training session was conducted for 50 clinic staff, primarily family practice residents. A training manual: Promoting and Supporting Breastfeeding in Your Clinic, was developed and provided to attendees. Participant evaluations showed that the session was well received and identified areas where further training and follow-up are needed: 74% of family practice residents (n=23) strongly agreed that the session expanded their understanding of the clinical aspects of BF; 78% strongly agreed that the session piqued their interest in the role of the physician and clinic in promoting BF; 60% strongly agreed that the session gave specifics for what they can do to promote BF; 39% strongly agreed and 52% agreed that they understood the counseling process; 30% strongly agreed and 70% agreed that they know where to document BF support and education in the medical record. Follow-up and feedback are crucial in helping physicians and clinics adopt and maintain new programs. A chart audit is being conducted to access actual BF promotion practices. We will continue to assist the clinic in implementing and monitoring this breastfeeding initiative.

The effects of therapeutic touch on patients with osteoarthritis of the knee

The purpose of this study was to determine if therapeutic touch, an alternative medicine modality, is effective in the treatment of osteoarthritis of the knee.A single-blinded randomized control trial was conducted in a family practice center of a community hospital family practice residency program in Pennsylvania. The patients were between the ages of 40 and 80, had been given a diagnosis of osteoarthritis of at least one knee, had not had knee replacement, and had no other connective tissue disease. The patients were randomized to therapeutic touch, mock therapeutic touch, or standard care. The main outcome measures were pain and its impact, general well-being, and health status measured by standardized, validated instruments, as well as the qualitative measurement of a Depth interview.Twenty-five patients completed the study. The treatment group had significantly decreased pain and improved function as compared with the placebo and control groups. The qualitative Depth interview confirmed this result.Despite the small numbers, significant differences were found in improvement in function and pain for patients receiving therapeutic touch. A larger study is needed to confirm these results. Alternative therapies can neither be accepted nor rejected without being subjected to the scientific method.

Enhanced obstetrics training for family practice residents: a unique collaborative program.

Access to obstetric services in rural areas has been and continues to be a challenge. 4 When available, much of the obstetric care in these areas has been provided by family physicians. I ,5 Unfortunately, the number of family physicians who practice obstetrics has been in decline. In 1996 only 26% of active members of the American Academy of Family Physicians included obstetrics in their practice. Although rural family physicians are more likely than their urban counterparts to provide maternity care, less than one half perform routine deliveries. The obstetric services needed in rural areas include access to providers who can perform cesarean deliveries.7 Norris et al performed a survey of 41 rural hospitals in Washington State. They found that most of these hospitals depend on family physicians for this operative intervention. Furthermore, they found that a family physician's comfort in doing cesarean deliveries was closely related to their formal training during residency. Opportunities for advanced obstetric training have included the following: (1) an emphasis on obstetrics (including operative obstetrics) during residency training; (2) I-year fellowship programs (typically community-based programs that emphasize skills for rural practice including obstetrics)9,lo; (3) onthe-job training in the communities or in some other nonresidency setting; (4) rural training tracks with a strong emphasis on obstetrics ; and (5) combined family practice-obstetrics programsY Although the importance of having family physician educators to model advanced obstetric skills is critical, it is also important to improve educational ties between departments of family practice and obstetrics and gynecology. As stated by Caudle et aI, I It is time for academic medical centers to

Developing occupational and environmental medicine curricula for primary care residents: project EPOCH-Envi. Educating Physicians in OCupational Health and the Environment.

To help primary care residency programs develop or improve residency curricula in occupational and environmental medicine, the National Institute for Occupational Safety and Health launched a train-the-trainer initiative. This project was called EPOCH-Envi (Educating Physicians in OCcupational Health and the Environment). From 1990 to 1996, 46 2-day curriculum development workshops were held. These featured (1) guidelines on how to plan, implement, and evaluate a curriculum, (2) continuing education on occupational illnesses and injuries, (3) a worksite or environmental site visit, and (4) information resources. A total of 435 faculty from 305 residency programs participated, representing 42.5% of the family practice residencies and 24.9% of the internal medicine residencies in the United States. A survey conducted among attendees (60.4% response rate) 17 months after their workshop revealed that 65.6% of respondents had added lectures on occupational and environmental topics to the residency curriculum. Other curriculum improvements were also made. Primary care physicians manage most patients with occupational and environmental health problems or concerns. Providing technical assistance specifically designed to support occupational and environmental health education in primary care residencies can have a positive impact on curriculum content.

Rationality in medical treatment decisions: is there a sunk-cost effect?

Objective: To assess residents' propensity to display the sunk-cost effect, an irrational decision-making bias, in medical treatment decisions; and to compare residents' and undergraduates' susceptibility to the bias in non-medical, everyday behaviors. Design: Cross-sectional, in-person survey. Setting: Louisiana State University, two locations: Medical Center-Baton Rouge and Main Campus-Psychology Department. Participants: Internal medicine and family practice residents ( N=36, Mdn age=27) and college undergraduates ( N=40, Mdn age=20). Measurements and main results: Residents evaluated medical and non-medical situations that varied the amount of previous investment and whether the present decision maker was the same or different from the person who had made the initial investment. They rated reasons both for continuing the initial decision (e.g., stay with the medication already in use) and for switching to a new alternative (e.g., a different medication). There were two main findings: First, the residents' ratings of whether to continue or switch medical treatments were not influenced by the amount of the initial investment ( p's>0.05). Second, residents' reasoning was more normative in medical than in non-medical situations, in which it paralleled that of undergraduates ( p's<0.05). Conclusions: Medical residents' evaluation of treatment decisions reflected good reasoning, in that they were not influenced by the amount of time and/or money that had already been invested in treating a patient. However, the residents did demonstrate a sunk-cost effect in evaluating non-medical situations. Thus, any advantage in decision making that is conferred by medical training appears to be domain specific.