Family Medicine Programs Research Articles

Equipping Residents to Address Alcohol and Drug Abuse: The National SBIRT Residency Training Project

The Screening, Brief Intervention and Referral to Treatment (SBIRT) service for unhealthy alcohol use has been shown to be one of the most cost-effective medical preventive services and has been associated with long-term reductions in alcohol use and health care utilization. Recent studies also indicate that SBIRT reduces illicit drug use. In 2008 and 2009, the Substance Abuse Mental Health Service Administration funded 17 grantees to develop and implement medical residency training programs that teach residents how to provide SBIRT services for individuals with alcohol and drug misuse conditions. This paper presents the curricular activities associated with this initiative. We used an online survey delivery application (Qualtrics) to e-mail a survey instrument developed by the project directors of 4 SBIRT residency programs to each residency grantee's director. The survey included both quantitative and qualitative data. All 17 (100%) grantees responded. Respondents encompassed residency programs in emergency medicine, family medicine, pediatrics, obstetrics-gynecology, psychiatry, surgery, and preventive medicine. Thirteen of 17 (76%) grantee programs used both online and in-person approaches to deliver the curriculum. All 17 grantees incorporated motivational interviewing and validated screening instruments in the curriculum. As of June 2011, 2867 residents had been trained, and project directors reported all residents were incorporating SBIRT into their practices. Consistently mentioned challenges in implementing an SBIRT curriculum included finding time in residents' schedules for the modules and the need for trained faculty to verify resident competence. The SBIRT initiative has resulted in rapid development of educational programs and a cohort of residents who utilize SBIRT in practice. Skills verification, program dissemination, and sustainability after grant funding ends remain ongoing challenges.

Medical care: elitism or social commitment?

As a director of a family medicine programme at the American University of Beirut Medical Center, Beirut, I have to make sure that residents receive proper training. The programme I work on is based in a tertiary care hospital. This has its pluses and minuses. Our paediatrics load is minimal, and the number of deliveries requested by the Accreditation Committee for Graduate Medical Education in the US is difficult if not impossible to attain in my setting. Having a satellite clinic in a marginalised community may overcome these barriers. With the help of a resident, I identified a non-governmental organisation (NGO) that runs a clinic in Sabra Camp in Beirut. After listening to a presentation by a doctor who worked in that clinic I visited the place. The road to the clinic is narrow and barely allows the passage of two cars. This puts the cars of residents and faculty at risk of accidents. If an accident happens, neither the NGO nor the institution we work in will cover that. One of our faculty members was against sending our residents to this clinic as it will give an impression that family medicine is a specialty for the poor! After reviewing the website of the NGO, I realised that occasionally there are armed clashes between two clans in the area, which puts the residents and me in danger. In this situation lives are at risk. Why then send the residents to this set-up? My visit included the clinic and the ‘houses’ of three families in the community. The clinic consisted of three rooms, a kitchen, one bathroom, and a terrace. The doctor's room occupied less than 9m2 area; but it serves the purpose. The other two rooms were bigger and are around 12m2 each. One room is used to …

SPICES Model perspectives for Saudi Board Family Medicine Program: Moving Away from the Sage on the Stage

SPICES Model perspectives for Saudi Board Family Medicine Program: Moving Away from the Sage on the Stage

Reflections on the development of family medicine in the Western Cape: a 15-year review

This article reviews how the model of family medicine has developed over the last 15 years in the Western Cape. It is based on a series of in-depth interviews with key role players. This period coincides with the immediate post-apartheid era, in which both the health system and health science education experienced rapid transformation. The new focus on primary health care, the district health system and community-based education provided an opportunity for the disciplines of family medicine and in primary care to develop. The model that emerged required the family physician to work at both the district hospital and in primary care, and to have a number of different roles: care provider, consultant, capacity builder, supervisor, manager and community leader. Family medicine was accepted as a new speciality in 2007. The first specialist family physicians will qualify in 2011, and start to consolidate the model that has been developed. Although the model shows promise, a number of challenges still remain, in relation to the health system, the relationship between universities and the province, the discipline of family medicine, research, and training programmes. It is hoped that these reflections will be of value to other provinces in South Africa, and other countries in the region, that are also thinking of including family physicians in their health systems.

Otolaryngology Education in Family Medicine and Communication Sciences Training

To characterize the extent and format of otolaryngology instruction during family medicine and communication disorders training and to determine the comfort level of graduate trainees to assess specific hearing disorders. Online surveys were sent to program directors in the fields of family medicine, audiology, and speech pathology. Directors were asked to delineate methods of teaching otolaryngology-related material and to define how often otolaryngologists were involved in their curricula. They were also asked to rate their graduate trainees' ability to manage 3 clinical scenarios involving pediatric hearing impairment. A total of 682 surveys were sent using e-mail addresses from the American Medical Association and the Council of Academic Programs in Communication Sciences and Disorders. Response rates were 20% for family medicine programs and 30% for each of the communication science disciplines. Virtually all respondent family medicine programs have dedicated instruction in otolaryngology, typically in the form of a clinical rotation (98%). Ninety-five percent of audiology programs involve an otolaryngologist in teaching compared with 55% of speech pathology programs. Otolaryngology-related diagnostic examination skills are taught by most programs in all 3 disciplines; confirmation of skills acquisition, however, is lacking. Directors rated the competence of their trainees to manage hearing disorders at an average of 3.4 for audiology, 2.7 for speech pathology, and 2.6 for family medicine graduates on a 4-point scale. Respondent directors from all 3 disciplines make a concerted effort to teach otolaryngology-related topics. A greater emphasis on those otolaryngology disorders requiring multidisciplinary care appears necessary, as does more formal instruction in and competency evaluation of diagnostic examination skills.

SP4-7 Health students' knowledge and needs relating to global health and health equity: a province-wide study

The purpose of this study is to evaluate the extent of global health content in the current curricula of family medicine, nursing and physiotherapy programs and to conduct a survey...

Evaluation of Standard Endotracheal Intubation, Assisted Laryngoscopy (Airtraq), and Laryngeal Mask Airway in the Management of the Helmeted Athlete Airway: A Manikin Study

Physicians at sporting events must rarely manage the airway of a helmeted athlete. This poses challenges for providers who do not regularly engage in airway management. In a manikin model, our purpose was to determine (1) if standard endotracheal intubation (ETI) of a simulated helmeted athlete is adversely affected by bright-light conditions and (2) if the use of laryngeal mask airway (LMA) or Airtraq improves airway management success. This is a randomized, prospective, crossover study. The study was conducted at a 500-bed community-based hospital with residency training programs in family medicine and emergency medicine, as well as a fellowship in sports medicine. We randomized 42 residents to manage the airway of a simulated helmeted athlete in c-spine immobilization using ETI, Airtraq, and LMA. Each method was attempted under bright light and in standard light. Our main outcomes were success or failure of airway and time to airway. Secondary outcome was perceived difficulty in airway management as a factor of environmental factors. Airway success rates were 93% for ETI, 99% for LMA, and 75% for Airtraq. Standard ETI was significantly faster than intubation using the Airtraq (P = 0.0001) and had greater success (P = 0.004). Time to airway was faster with LMA than with standard ETI (P < 0.00001). There was no impact of bright light on ETI time (P = 0.61). These results suggest that both ETI and LMA may be acceptable choices for management of the airway in the helmeted athlete. Time to airway was significantly decreased with the use of LMA, regardless of the experience level of the intubator. Lighting conditions had no effect on success.

Sleeping at Home: A New Model for a Hospital Teaching Service

The traditional marriage between teaching hospitals and residents pivots on a central prenuptial agreement: residents offer their hospitals round-the-clock patient care, and, in exchange, hospitals provide an experiential learning modality. This long-held covenant may require an update due to 3 significant changes: the increased spotlight on protecting resident education from excessive service demands; the development of hospital medicine as a specialty; and the need to provide more experiential learning in ambulatory care settings for primary care programs, including family medicine. The rapid growth of hospitalist care—84% of all teaching hospitals in the United States have at least 3 hospitalists1—has been sparked in part by pressure placed on primary care doctors to increase outpatient visits and on hospitals to reduce length of stay.2 The desire to have better work/life balance coupled with fewer inpatient admissions and increased financial demands have resulted in a decline in family medicine physicians who provide both inpatient and outpatient care. Many hospitals are moving to hospitalist care, citing improved care and decreased cost.,3,4 In 2006, the year before we implemented our new model of inpatient teaching, 62.5% of our program's new graduates entered into practice without an inpatient component. We describe a unique adult inpatient teaching service in a family medicine residency program that integrates resident teaching with hospitalist care. The novelty stems from the use of hospitalists, not residents, as the primary workforce in the hospital. By uncoupling the educational experience of teaching residents how to care for hospitalized patients from the service demands of the hospital, it is possible to achieve both of these goals and comply with duty hour limits. The added advantage of our system is that residents are able to spend more time in the outpatient setting. This gain in ambulatory training aligns with most of our residents' postgraduation plans to work as primary care physicians in the outpatient setting.

An International Health Track Is Associated With Care for Underserved US Populations in Subsequent Clinical Practice

Recent efforts to increase insurance coverage have revealed limits in primary care capacity, in part due to physician maldistribution. Of interest to policymakers and educators is the impact of nontraditional curricula, including global health education, on eventual physician location. We sought to measure the association between graduate medical education in global health and subsequent care of the underserved in the United States. In 2005, we surveyed 137 graduates of a family medicine program with one of the country's longest-running international health tracks (IHTs). We compared graduates of the IHT, those in the traditional residency track, and graduates prior to IHT implementation, assessing the anticipated and actual involvement in care of rural and other underserved populations, physician characteristics, and practice location and practice population. IHT participants were more likely to practice abroad and care for the underserved in the United States in the first 5years following residency than non-IHT peers. Their current practices were more likely to be in underserved settings and they had higher percentages of uninsured and non-English-speaking patients. Comparisons between pre-IHT and post-IHT inception showed that in the first 5years following residency, post-IHT graduates were more likely to care for the underserved and practice in rural areas and were likely to offer volunteer community health care services but were not more likely to practice abroad or to be in an academic practice. Presence of an IHT was associated with increased care of underserved populations. After the institution of an IHT track, this association was seen among IHT participants and nonparticipants and was not associated with increased long-term service abroad.

Updated survey of the geriatrics content of canadian undergraduate and postgraduate medical curricula.

A survey in 2005 determined the hours of mandatory geriatrics content in Canadian undergraduate and postgraduate medical curricula. The present survey was undertaken to update these data for 2008-9. A survey was sent to a designated geriatrician at each medical school. The mandatory geriatrics content of the undergraduate curricula ranged between 10 and 299 hours, with a mean of 82. Seven of 16 schools had a mandatory clerkship rotation of a least 1 week. Fourteen family medicine programs had a rotation in geriatric medicine and all psychiatry programs required a rotation in geriatric psychiatry. A geriatric rotation was mandatory for six internal medicine, six neurology, five physiatry, one orthopedic, and one emergency medicine program. In comparison to 2004-5, the mean hours of geriatrics teaching in the undergraduate curricula had increased from 78 to 82. However, two schools saw a decrease in preclerkship teaching and one school lost a 2-week clerkship. Postgraduate requirements had changed little overall, with the exception that, for emergency medicine, geriatrics was now mandatory for only one program, instead of three. Although the total number of hours of teaching in geriatric medicine in the undergraduate curricula had increased slightly in 2008-9 compared to 2004-5, in some schools teaching hours were reduced. In the postgraduate curricula emergency medicine requirements for geriatrics were reduced. Of greater importance is determining which core competencies are being taught and mastered, and this is an area of ongoing study.

Cardiac Disease and Heart Failure in Cancer Patients: Is Our Training Adequate to Provide Optimal Care?

The care of patients with cancer who have cardiac disease is dispersed both sequentially and concurrently across multiple providers, and an important goal of education is communication among the providers regarding change of therapy, toxicity of therapy, and symptom assessments. Changes must be made to improve the delivery of cardiac care in patients with cancer and cancer survivors. Therefore, the authors propose a multilevel approach that includes short, targeted curriculum for housestaff training programs in internal medicine, family medicine, pediatrics, cardiology and oncology; increasing presence at national meetings of internists, oncologists and cardiologists; and an Internet-based repository of core information.

Has mifepristone medical abortion expanded abortion access in New Mexico? A survey of OB-GYN and Family Medicine physicians

Background The FDA approval of mifepristone in 2000 broadened the available options for abortion. The aim of this study was to evaluate whether physicians in New Mexico have integrated the use of mifepristone into their practice. Study Design We performed a mail-out survey of New Mexico Obstetrician Gynecologists (Ob-Gyn) and Family Medicine (FM) physicians in 2001 and 2008. Questions addressed integration of abortion services, attitudes towards providing abortion in different scenarios and barriers to offering abortion services. Results The response rates were 59% for the 2001 survey and 54% in 2008. In 2001 and 2008, 11% and 15% (p=.26) of physicians, respectively, provided any abortion — medical or surgical. Similarly, in 2001 and 2008, 5% and 10% (p=.07) provided medical abortion. Commonly cited barriers to provision of abortion in both years were beliefs against abortion and lack of training. Conclusions The number of physicians offering any abortion or medical abortion in New Mexico has not changed since the FDA approval of mifepristone. Residency training programs in FM and in Ob-gyn should include training in medical abortion.

Integrating Addiction Medicine Into Graduate Medical Education in Primary Care: The Time Has Come

Substance use disorders create an enormous burden of medical, behavioral, and social problems and pose a major and costly public health challenge. Despite the high prevalence of substance use and its consequences, physicians often do not recognize these conditions and, as a result, provide inadequate patient care. At the center of this failure is insufficient training for physicians about substance use disorders. To address this deficit, the Betty Ford Institute convened a meeting of experts who developed the following 5 recommendations focused on improving training in substance abuse in primary care residency programs in internal medicine and family medicine: 1) integrating substance abuse competencies into training, 2) assigning substance abuse teaching the same priority as teaching about other chronic diseases, 3) enhancing faculty development, 4) creating addiction medicine divisions or programs in academic medical centers, and 5) making substance abuse screening and management routine care in new models of primary care practice. This enhanced primary care residency training should represent a major step forward in improving patient care.

Expediency and coincidence in re-engineering a health system: an interpretive approach to formation of family medicine in Iran

Analysing the evidence generated over decades, the World Health Report 2008 recommended the expansion of primary health care (PHC) to achieve better population health, higher equity and lower costs. Over the last two decades, the Iranian model of PHC has resulted in population health indices that match the best in the region. Despite the extensive PHC networks in rural areas, there was an expansion of private outpatient care and hospital-based services. This model has been inadequate to meet the evolving health needs of the population and increasingly difficult to afford. In response, a family medicine (FM) programme has been implemented since August 2005, funded through Behbar, a model of social insurance. In this paper, we aim to identify facilitators of and barriers to implementation of FM in Iran. Data were collected between November 2006 and May 2007 through semi-structured interviews at national (19 interviews), provincial (9) and local (43) levels, and through a purposive document analysis. The framework approach was used for analysing interviews. Document analysis followed a narrative contextual framework. We interpreted data using an interpretive framework consisting of multiple streams and network theories. The introduction of Behbar provided FM advocates with the opportunity to place FM on the policy agenda. They skillfully coupled the two policies and defined FM as the only solution to fulfill Behbar. However, the manner in which policy was formed was the main obstacle to desired FM implementation. The interpretive framework links the concept of outreach to the poor and enhancing equity to rationing health services at a particularly opportune moment in Iran. However, using windows of opportunity to implement a major policy change, if it results in sacrifices in planning and preparedness, may harm the policy and the future success in achieving its objectives.

Primary care perceptions of otolaryngology

Objective To identify diseases of the head and neck for which primary care physicians may underappreciate the role of the otolaryngologist. Study Design Cross-sectional analysis. Setting With increasing subspecialization in the world of medicine, there is the potential for confusion about the scope of practice for different specialties by primary care physicians. These clinicians are often faced with patients who have disease processes in which otolaryngologist are trained but may end up referring patients to other specialists. Subjects and Methods A brief, web-based survey was administered via e-mail to resident physicians of family medicine, pediatrics, and internal medicine programs in the United States. The survey asked responders which specialist they believed was an expert for particular clinical entities: allergies, oral cancer, restoring a youthful face, sleep apnea, thyroid surgery, and tracheostomy. Respondents could choose from a dermatologist, general surgeon, ophthalmologist, oral maxillofacial surgeon, orthopedic surgeon, otolaryngologist, and plastic surgeon. The responder was able to choose more than one specialist for each question. Results A total of 1064 completed surveys were analyzed. The percentage of primary care residents who picked otolaryngologists as experts was 13.8 percent for allergies, 73.6 percent for oral cancer, 2.7 percent for restoring a youthful face, 32.4 percent for sleep apnea, 47.2 percent for thyroid surgery, and 72.5 percent for tracheostomy. Conclusion This study demonstrates that many primary care residents are not aware of the scope of expertise that an otolaryngologist may offer. Increased exposure to otolaryngology during primary care residency training may increase understanding of the specialty among primary care physicians.

Professional Perceptions of Plastic and Reconstructive Surgery: What Primary Care Physicians Think

The great breadth of the specialty of plastic surgery is often misunderstood by practitioners in other specialties and by the public at large. The authors investigate the perceptions of primary care physicians in training toward the practice of different areas of plastic and reconstructive surgery. A short, anonymous, Web-based survey was administered to residents of internal medicine, family medicine, and pediatrics training programs in the United States. Respondents were asked to choose the specialist they perceived to be an expert for six specific clinical areas, including eyelid surgery, cleft lip and palate surgery, facial fractures, hand surgery, rhinoplasty, and skin cancer of the face. Specialists for selection included the following choices: dermatologist, general surgeon, ophthalmologist, oral and maxillofacial surgeon, orthopedic surgeon, otolaryngologist, and plastic surgeon. A total of 1020 usable survey responses were collected. Respondents believed the following specialists were experts for eyelid surgery (plastic surgeon, 70 percent; ophthalmologist, 59 percent; oral and maxillofacial surgeon, 15 percent; dermatologist, 5 percent; and otolaryngologist, 5 percent); cleft lip and palate surgery (oral and maxillofacial surgeon, 78 percent; plastic surgeon, 57 percent; and otolaryngologist, 36 percent); facial fractures (oral and maxillofacial surgeon, 88 percent; plastic surgeon, 36 percent; otolaryngologist, 30 percent; orthopedic surgeon, 11 percent; general surgeon, 3 percent; and ophthalmologist, 2 percent); hand surgery (orthopedic surgeon, 76 percent; plastic surgeon, 52 percent; and general surgeon, 7 percent); rhinoplasty (plastic surgeon, 76 percent; otolaryngologist, 45 percent; and oral and maxillofacial surgeon, 18 percent); and skin cancer of the face (dermatologist, 89 percent; plastic surgeon, 35 percent; oral and maxillofacial surgeon, 9 percent; otolaryngologist, 8 percent; and general surgeon, 7 percent). As the field of plastic surgery and other areas of medicine continue to evolve, additional education of internal medicine, pediatrics, and family practice physicians and trainees in the scope of plastic surgery practice will be critical.

Resident-Initiated Integrative Medicine Curriculum in an Allopathic Family Medicine Residency

Although integrative medicine modalities are widespread and increasingly popular among patients and physicians, exposure to integrative medicine teaching remains limited during allopathic residency training. There is a need for innovative ways to incorporate integrative medicine teaching into family medicine residency training. In an allopathic family medicine program, residents developed an integrative medicine curriculum consisting of 37 weekly seminars tailored to the interests of the group. At the end of the academic year, the participants evaluated the program using a modified nominal group technique. Major strengths were the unique content, the joy and support shared with the group, and the inspiring experience. Participants suggested incorporating more practical applications and hands-on experiences in future seminars and protecting time for attendance. For residents with interest in integrative medicine, weekly resident-run teaching sessions support their personal and professional growth and may improve their overall spirit during residency. In residency programs with limited teaching in integrative medicine, residents can successfully take initiative and create their own curriculum with support from community providers and interested faculty.

Mother Cabrini and the Anatomy of an Illness

Mother Cabrini and the Anatomy of an Illness

Training in childhood obesity management in the United States: a survey of pediatric, internal medicine-pediatrics and family medicine residency program directors

BackgroundInformation about the availability and effectiveness of childhood obesity training during residency is limited.MethodsWe surveyed residency program directors from pediatric, internal medicine-pediatrics (IM-Peds), and family medicine residency programs between September 2007 and January 2008 about childhood obesity training offered in their programs.ResultsThe response rate was 42.2% (299/709) and ranged by specialty from 40.1% to 45.4%. Overall, 52.5% of respondents felt that childhood obesity training in residency was extremely important, and the majority of programs offered training in aspects of childhood obesity management including prevention (N = 240, 80.3%), diagnosis (N = 282, 94.3%), diagnosis of complications (N = 249, 83.3%), and treatment (N = 242, 80.9%). However, only 18.1% (N = 54) of programs had a formal childhood obesity curriculum with variability across specialties. Specifically, 35.5% of IM-Peds programs had a formal curriculum compared to only 22.6% of pediatric and 13.9% of family medicine programs (p < 0.01). Didactic instruction was the most commonly used training method but was rated as only somewhat effective by 67.9% of respondents using this method. The most frequently cited significant barrier to implementing childhood obesity training was competing curricular demands (58.5%).ConclusionsWhile most residents receive training in aspects of childhood obesity management, deficits may exist in training quality with a minority of programs offering a formal childhood obesity curriculum. Given the high prevalence of childhood obesity, a greater emphasis should be placed on development and use of effective training strategies suitable for all specialties training physicians to care for children.

Preventive Care of Liver Disease by Primary Care Providers

Purpose: Cirrhosis is the 12th leading cause of mortality in the US. Preventive care in cirrhosis may improve survival. We hypothesized primary care providers wouldn't provide some preventive care services to patients with cirrhosis. Methods: We developed an anonymous survey to assess physician knowledge of preventive care in cirrhosis patients. To minimize bias, the survey contained a variety of questions and subjects were told the purpose was to assess general GI knowledge. All US internal and family medicine program directors were invited to encourage their residents and faculty to participate. The survey was also posted on 2 online physician communities. The following demographic information was collected: age, gender, date of medical school graduation, specialty, attending vs. resident, percent of time in critical care, academic practice vs. private practice, and geographic area of practice. Subjects were presented a vignette of a 55 year old female with compensated cirrhosis due to hepatitis C who presents for an initial primary care visit. Subjects were presented a list of 16 choices of appropriate preventive care actions for the case patient. 8 of the choices were considered valid responses. The key item for analysis was the selection of abdominal ultrasound for hepatocellular carcinoma screening. Results: 581 physicians responded. 39% were attending physicians and 61% were residents. 42% were family practice physicians; 56% were internal medicine physicians. 75% of subjects practice in an academic setting and 25% in the private setting. Analyses used Fishers extact test with a p value of statistical significance < 0.05. Comparisons were made for the following categories: attendings vs. residents, internal medicine vs. family medicine, age in 10 year increments, academic vs. private practice. 72 % of subjects did not select abdominal ultrasound for the case patient. Residents were significantly less likely to select abdominal ultrasound than attending physicians (25% vs. 33%; p = 0.04); family physicians were less likely to select abdominal ultrasound than internal medicine physicians (20% vs. 35%; p = 1.22 × 10-4). Conclusion: Hepatocellular carcinoma is a leading cause of death in patients with cirrhosis. This survey suggests that primary care physicians significantly under screen cirrhotic patients for hepatocellular carcinoma. More study is needed to ascertain the overall impact of this finding on care of cirrhotic patients since gastroenterologists/hepatologists may provide the bulk of preventive care in this population.