Family Practice Residency Research Articles

A Family Practice Residency Cervical Screening Project

A Family Practice Residency Cervical Screening Project

A case for the development of family practice rural training tracks.

Enthusiasm for alternate training sites has been strong among practicing family physicians and students seeking family practice residency positions in Wisconsin. The number of rural training tracks in the state is increasing rapidly. The University of Wisconsin currently has 4 residents in two rural training tracks. If 1998 recruitment is successful, there will be 12 residents in seven rural training tracks operated by two sponsoring institutions in the state. The WIsconsin rural training tracks are 1-2 programs,! in which the family practice resident spends the first year in the urban medical center of the home program completing appropriate rotations, such as internal medicine, pediatrics, obstetrics-gynecology, emergency medicine, surgery, and critical care, and the last 2 years in a rural community and rural hospital as an apprentice with a family practice group. During the last 2 years, the resident can receive longitudinal training in specialty areas with visiting subspecialists and can spend time away from the rural medical practice for specialty rotations not available in the rural setting. The development of the WIsconsin rural training tracks was based in part on the pioneering work of Rosenthal et al. 2 The process used to develop the first rural training track was adopted as a template for developing other rural training tracks in WIsconsin and in other states} Not much has been published, however, assessing educational outcomes and documenting the effects of rural training tracks on communities. Despite this lack of documentation, we believe rural tracks have merit as a training model for family practice and

Patient Knowledge of Upper Respiratory Infections

Background Upper respiratory infections (URIs) account for many of the visits in primary care and are commonly treated with ineffective antibiotic therapy. The purpose of this study was to examine patient beliefs in the effectiveness of antibiotics and the likelihood of seeking care for normal presentations of URIs. Methods We conducted a survey of 961 adults (> or = 18 years of age) from an undifferentiated patient population in a university-based family practice residency clinic in metropolitan Kentucky, a private internal medicine practice in nonmetropolitan Kentucky, and, in metropolitan Louisiana, an emergency department and a convenience sample from the community. Results Seventy-two percent of the sample reported that they would seek care with a condition of 5 days' duration with cough, sore throat, and discolored nasal discharge. Sixty-one percent of the sample expressed their belief that antibiotics are effective for a condition of 5 days' duration with cough, sore throat, and clear nasal discharge; 79% said that they believed antibiotics are effective when there is discolored discharge (P = .0001). Medicaid recipients were most likely to seek care across the symptom complexes. Higher education was related to a decreased belief in the effectiveness of antibiotics for the scenario with clear discharge (P .001), but to an increased belief in the effectiveness of antibiotics in the scenario with discolored discharge (P = .003). The strongest predictor of both likelihood of utilization and belief in effectiveness of antibiotics was usual use of antibiotics for the URI symptom complexes. Conclusions Patients lack understanding of the normal presentation of a URI and the effectiveness of antibiotics as a treatment. A confusion about the meaning of discolored nasal discharge is particularly evident, and past antibiotic use may contribute to inappropriate utilization and expectations for antibiotics.

Geriatrics in Generalist Resident Training

Internal Medicine and Family Practice residency graduates were surveyed to obtain baseline data prior to enhancement of geriatrics content in residency training, and to evaluate one purported obstacle to increasing geriatrics training in residency programs, that of resident disinterest in such training. The majority of residents indicated that additional training in geriatrics would have been useful in their current practice. Only one third felt the geriatrics education received during residency was adequate to meet the needs of their practice. Attitudes toward older patients were consistently positive. Competency to diagnose and treat problems in gait and continence was limited. These data provide compelling evidence of residents' perceived need for enhanced training in geriatrics. Residents clearly understand the impact of demographic trends on future practice, and recognize the importance of adequate preparation in geriatrics. Further research should explore potential barriers other than resident attitudes to the integration of geriatrics content into generalist residency training programs.

Cancer screening of older women : a primary care issue.

The purpose of this retrospective chart review was to examine whether family practice physicians and residents were screening older women for breast, gynecologic, and colorectal cancers as recommended by the American Cancer Society, the Guide to Clinical Preventive Services, and Healthy People 2000. A retrospective chart review of women 60 years and older who were seen at least twice between July 1, 1992, and June 30, 1993, in a midwestern family practice residency program was completed. From the original sample of 660 potential subjects, a systematic random selection of every third chart was identified for review, resulting in a sample of 201. Analysis of the data was performed by descriptive statistics and chi-square tests. A series of multiple regression models using age, number of visits, type and gender of provider, and personal or family history of cancer as predictor variables was performed. Breast cancer screening was offered to approximately 70% of the sample, with only about one third of the older women receiving mammography or clinical breast examination. Recommendations for gynecologic cancer screening were given to 63% of the sample, with less than one third receiving Papanicolaou smears. Recommendations for digital rectal examination, fecal occult blood test, and flexible sigmoidoscopy were 58%, 59%, and 30%, respectively. The percentages of patients who actually received these tests were considerably lower. Barriers for appropriate cancer screening for older women exist for both the provider and the patient; however, many of these obstacles can be overcome. Improving the resident's exposure to the current recommendations, increasing geriatric content in the training program, and initiating a reminder system may reduce some of the provider barriers. The use of midlevel providers may increase the preventive services offered to older women as well as educate and empower these women to become responsible for their own healthcare. Together, physicians and midlevel providers can become patient advocates through political activism, encouraging legislation that guarantees payment for cancer screening tests. Finally, primary care providers can become actively engaged in research that explores the healthcare concerns of older women.

Maternity care practices of navy family practice residency graduates after leaving the military.

Nationwide, 32% of residency-trained family physicians deliver babies compared with 73% to 90% in the military. This study describes and defines issues that could ultimately help revive family practice maternity care. We surveyed 112 family physicians who had left the navy. Ninety-one percent had delivered babies in the navy, 45% since leaving the military, and 25% currently. Principal maternity care incentives both in and out of the military were personal and professional satisfaction. Reasons for not providing civilian maternity care included malpractice risks, insurance costs, and lifestyle issues. The decision for providing maternity care was usually made before or during residency, whereas the decision against was most often made upon leaving the military. Among more recent graduates (1990-1995), 48% continued to deliver babies in civilian practice. (This is about 20% more than recent civilian graduates.) Malpractice concerns were less important to this group than to earlier graduates. Factors discouraging family physicians from providing maternity care arise from their practice environment and are not easily overcome with improved training and experience. Recent navy residency graduates are not as easily discouraged.

Orientation To Social Medicine and The Bronx: An Educational Experience For Adult Learners

Background: Little attention has been paid to the orientation process used to assist residents in their transition from student to physician. Description: The Residency Program in Social Medicine of the Montefiore Medical Center/Albert Einstein College of Medicine developed an innovative orientation for 1st-year residents in primary care internal medicine, pediatrics, and family practice, built on the principles of adult education. Evaluation: Formative evaluation questionnaires from four orientation cohorts, 1990-93, were analyzed (total residents = 77, respondents = 66, response rate = 86%), including both quantitative (Likert scale) and qualitative assessments of its goals and learning activities. Over the 4 years analyzed, 95%of the residents' median evaluation met or exceeded their expectations. More than 60%of the residents' median evaluations of all learning activities were rated very good to excellent. Qualitative evaluations highlighted both the special virtues and drawbacks of such an adult learning experience. Conclusions: This orientation conforms to the principles of adult education and has consistently achieved its goals in orienting residents to the history, organization, and culture of their clinical institutions and community.

A field trial of 2 telemedicine camera systems in a family practice.

Previous reports of telemedicine consultations have demonstrated that the technology is effective but inefficient. Little attention has been directed to the use of telemedicine in a primary care practice, especially the use of the medical peripheral devices. We used a functioning primary care practice as a telemedicine test bed, providing unselected patients in the study group. The goal was to study the performance of a new generation of a compact set of medical peripheral devices specifically designed for telemedicine examinations. In a 3-week field trial, 2 second-generation camera systems were used by physician faculty and residents in family practice to examine the skin, ears, and pharynx of 34 patients, ranging in age from 10 months to 78 years. Evaluations by the clinicians and patients were obtained. The average duration of an examination using these systems was 2 minutes. Patients' response was uniformly positive. A "pistol grip" video otoscope obtained an acceptable image, unless canal debris obscured the view. The system that provided pneumatic otoscopy was preferred, with some modifications necessary to obtain an airtight seal. The preferred skin camera was one that provided an image of a size that clinicians were most accustomed to viewing, although stability of this handheld camera was a problem. This camera also worked well to visualize the pharynx, especially in children with symptoms of pharyngitis. Color was deemed important in all 3 anatomical areas, and using auto-white balance and excluding fluorescent lights were preferred. Thus, the second-generation telemedicine peripheral devices were effective for use in a group of unselected primary care patients. These camera systems can be used by nursing personnel and require a minimum of time per examination.

Neonatal circumcision and pain relief: current training practices.

We conducted a national survey of pediatric, family practice, and obstetrics and gynecology residency program directors to determine the curriculum content and predominant practices in US training programs with regard to neonatal circumcision and anesthesia/analgesia for the procedure. Residency directors of accredited programs were surveyed in two mailings of a forced response and short answer survey (response rate: 680/914, 74%; pediatrics 83%; family practice 72%; obstetrics 71%). Pediatric residents were less likely than family practice [odds ratio (OR), 0.04; 95% confidence interval (CI), 0.02-0.08] or obstetrical (OR, 0.14; 95% CI, 0.08-0.23) residents to be taught circumcision. Training and local custom were rated as important determinants of medical responsibility for neonatal circumcision. Pediatric residents training in programs in which community pediatricians perform circumcisions were more likely to learn circumcision (OR, 39.0; 95% CI, 14.3-110.6) as were obstetric residents (OR, 79.0; 95% CI, 22.4-306.4) training in programs in which community obstetricians perform circumcision. In programs that teach circumcision, pediatric (84%; OR, 3.4; 95% CI, 1.7-7.1) and family practice (80%; OR, 2.7; 95% CI, 1.7-4.2) programs were more likely than obstetric programs (60%) to teach analgesia/anesthesia techniques to relieve procedural pain. Overall, 26% of programs that taught circumcision failed to provide instruction in anesthesia/analgesia for the procedure. Significant regional variations in training in circumcision and analgesia/anesthesia techniques were noted within and across medical specialties. Residency training standards are not consistent for pediatric, family practice, and obstetrical residents with regard to neonatal circumcision or instruction in analgesia/anesthesia for the procedure. Training with regard to pain relief is clearly inadequate for what remains a common surgical procedure in the United States. Given the overwhelming evidence that neonatal circumcision is painful and the existence of safe and effective anesthesia/analgesia methods, residency training in neonatal circumcision should include instruction in pain relief techniques.

Training the trainers: substance abuse screening and intervention.

Screening and brief intervention for substance abuse is effective yet underutilized by primary care physicians. This article reports on Project SAEFP (Substance Abuse Education for Family Physicians), which aimed to enhance the clinical and teaching skills and activities of U.S. family practice residency faculty. Ten five-day workshops were designed and administered for 165 participants. Evaluation data included measures of participant satisfaction and pre-workshop and twelve-month post-workshop measures of the frequency of teaching, consulting, and clinical activities, and the attainment of self-identified teaching goals. The participants were very satisfied with the workshops. They improved significantly in the key outcome measures. Several workshops may have contributed to the apparent success of Project SAEFP. Attributes of the workshops which might have facilitated their success were their duration, funding, frequency of offering, collegial learning environment, opportunities for active learning, emotionally moving exposure to recovering individuals, focus on how to modify curriculum at participant residency programs, availability of family physician role models as faculty, and readily usable instructional materials. Planners of interventions for physician educators might profit from similar attention to these attributes.

Domestic Violence

Summary In this paper, the authors outline their experience in incorporating a curriculum on domestic violence into an urban family practice residency program. Based on the concept that in order to successfully develop such a curriculum, it is necessary to address the “culture of the organization,” joint educational strategies that in-elude resident education as well as faculty development were considered. A research question was designed to inquire as to the difference in the level of knowledge about domestic violence in family practice faculty as compared to residents prior to the introduction of educational strategies. The authors describe curriculum goals and objectives and outline specific teaching methods as well as the evaluation instrument utilized in the study to measure actual difference in knowledge between faculty and residents about domestic violence with a focus specifically on spousal abuse. Their conclusions point to the need for an educational strategy that includes emphasis on the faculty-resident interface which utilizes both traditional and non-traditional integrated formats in order to successfully train residents in the identification and treatment of domestic violence.

Training for collaboration: Suggestions for the joint training of mental health clinicians and family practice residents.

Training for collaboration: Suggestions for the joint training of mental health clinicians and family practice residents.

Pap Smear Adequacy

BACKGROUND AND OBJECTIVES The Papanicolaou (Pap) smear is a widely accepted tool for the detection and prevention of cervical cancer. Under the Bethesda Scoring System, the key internal control for adequacy of the smear is the presence of endocervical cells. Over the past several decades, much effort has been undertaken to maximize the adequacy of this acquisition. The present study determined if Pap smear sample adequacy is related to clinician experience. METHODS This study includes a retrospective analysis of 1,356 Pap smears acquired between January 1992 and January 1995. The procedures were performed by family practice residents and faculty physicians. Cervical smears were obtained with a combination of a cytobrush and an Ayre spatula and were placed on two slides. Adequacy was subsequently determined by a cytotechnologist. Chi-square analysis was used to determine if the adequacy rates for faculty and for PGY-1, PGY-2, and PGY-3 residents were significantly different. RESULTS The adequacy rates for PGY-1, PGY-2, PGY-3 residents and faculty physicians were 80%, 89%, 89%, and 93%, respectively. The adequacy rates for the first-year residents were significantly different from that of all other studied groups. CONCLUSIONS This study demonstrates the relationship between clinician experience and the ability to perform an adequate Pap smear. Considering the cost and potential medical risk of an inadequate Pap smear, family practice residency programs should increase the degree of PGY-1 education and experience in performing Pap smears.

On-Site Colposcopy Services in a Family Practice Residency Clinic

Background: Using colposcopy as a model, we examined the impact of introducing a new diagnostic. technology into the ambulatory primary care setting. Methods: Records of patients with abnormal findings on Papanicolaou smears were reviewed from three study periods: 1 year before, 1 year after, and 5 years after initiation of on-site colposcopy services. Data analyzed include physician management decisions, site of colposcopic service, and patient compliance. Practice revenue estimates were based upon patterns of physician management and patient compliance found during each study period. Results: Management of low-grade squamous intraepithelial lesions varied during each study period. By period 3, however, most patients were undergoing colposcopy (P = 0.03). High-grade squamous intraepithelial lesions were uniformly managed with colposcopy during all study periods (P Conclusions: Although offering on-site colposcopy services might have had some impact on physician management of low-grade squamous intraepithelial lesions, the lack of benefit regarding patient compliance, the relatively small patient volume for this procedure, and its modest impact on practice revenue cause us to question the value of including colposcopy in everyday practice.

Failed appointments in residency practices: who misses them and what providers are most affected?

Missed appointments can affect patient health, disrupt schedules, and result in poor utilization of resources, increased workload for staff and physicians, and lost learning opportunities for residents in training programs. The setting was an established community-hospital-based family practice residency practice averaging 25,000 outpatient visits per year in a small northern New England town. Data from a computer-scheduling system and hospital mainframe, as well as demographic and other information contained in billing records and patient schedules, were abstracted for patients who scheduled 3962 appointments on 36 sampled days during 1995. The missed appointment rate during the study period was 6.7 percent. Characteristics associated with missed appointments were younger patient age (17 to 30 years), Medicaid coverage or lack of health insurance, and appointments scheduled with first-year residents or medical students. Attention should be given to those patients most likely to miss appointments and, in training programs, to patients seeing first-year residents and medical students. It is possible that our relatively low missed appointment rate overall resulted from the nature of the practice and its environment.

Cardiac Auscultatory Skills of Internal Medicine and Family Practice Trainees

Medical educators have had a growing sense that proficiency in physical diagnostic skills is waning, but few data have examined the question critically. To compare the cardiac auscultatory proficiency of medical students and physicians in training. A multicenter cross-sectional assessment of students and house staff. A total of 8 internal medicine and 23 family practice programs of the mid-Atlantic area. A total of 453 physicians in training and 88 medical students. All participants listened to 12 cardiac events directly recorded from patients, which they identified by completing a multiple-choice questionnaire. scores were expressed as the percentage of participants, for year and type of training, who correctly identified each event. Cumulative scores were expressed as the total number of events correctly recognized. An adjusted score was calculated whenever participants selected not only the correct finding but also findings that are acoustically similar and yet absent. Trainees' cumulative scores ranged between 0 and 7 for both internal medicine and family practice residents (median, 2.5 and 2.0, respectively). Internal medicine residents had the highest cumulative adjusted scores for the 6 extra sounds and for all 12 cardiac events tested (P=.01 and .02, respectively). On average, internal medicine and family practice residents recognized 20% of all cardiac events; the number of correct identifications improved little with year of training and was not significantly higher than the number identified by medical students. Both internal medicine and family practice trainees had a disturbingly low identification rate for 12 important and commonly encountered cardiac events. This study suggests a need to improve the teaching and assessment of cardiac auscultation during generalists' training, particularly with the advent of managed care and its search for more cost-effective uses of technology.

The Maternity Care Practice of Navy Family Practice Residency Graduates While on Active Duty

Military family practice residency programs produce a high percentage of graduates who provide maternity care. This study will define the scope of maternity care practice for one military family practice residency program's graduates while they were serving on active duty in the U.S. Navy. Two hundred eight surviving graduates of the family practice residency at Naval Hospital, Jacksonville, Florida, from 1971 to 1995 were surveyed by mail regarding their maternity care practice while on active duty. One hundred eighty-one (87%) responded to the survey, and the data were analyzed with descriptive statistics. The vast majority of these Navy family practice residency graduates provided prenatal care (88.4%) and routine vaginal delivery services (85.1%) while on active duty. The majority repaired third- and fourth-degree perineal lacerations and performed vacuum- or forceps-assisted vaginal delivery. Additionally, a significant minority provided more advanced maternity care services such as dilation and curettage, tubal ligation, and cesarean section. The overwhelming majority (97%) of these graduates felt that their residency education had adequately prepared them to provide these maternity care services while on active duty. During the past 25 years, Navy residency-trained family physicians provided a wide range of maternity care services while on active duty and felt that their Navy residency training program had prepared them well to meet this responsibility.

Training for primary care of mentally handicapped patients in US family practice residencies.

As a result of managed care mandates for primary care and the growing community presence of the 6 million mentally handicapped persons in the United States, primary care of this population will increasingly be provided by family physicians. How much family practice residencies emphasize training for care of this population is the focus of this study. A questionnaire was mailed to each family practice residency program in the United States asking about didactic teaching, clinical activities, and faculty and curriculum planning related to care of the mentally handicapped population. Seventy-one percent of questionnaires were returned. Only 32 percent of respondents teach related didactic sessions, 24 percent plan clinic patient care for this population, and 42 percent affiliate with a residential care facility. The most frequently listed didactic topics were delayed infant assessment and seizure care. Comprehensive management of the mentally handicapped adult, family issues, behavioral problems, and long-term planning had low ratings compared with the first two topics. Psychiatrists were rated higher than family practice faculty for training in this area. There is little enthusiasm among residency directors about the need for training in care of mentally handicapped patients. Topics that are most valued, however, were those that are generally within the purview of specialists. A low value was placed upon training for helping families access services, behavior management, or comprehensive long-term planning-areas most often addressed by family physicians. Further studies are needed to assess the training needs of family physicians in caring for mentally handicapped persons.

Training Family Practice Residents in Abortion and Other Reproductive Health Care: A Nationwide Survey

The majority of residents responding to a 1995 survey of program directors and chief residents at 244 family medicine residency programs in the United States reported they had no clinical experience in cervical cap fitting, diaphragm fitting or IUD insertion and removal. For all family planning methods except oral contraceptives, no more than 24% of residents had experience with 10 or more patients. Although 29% of programs included first-trimester abortion training as either optional or routine, only 15% of chief residents had clinical experience providing first-trimester abortions. Five percent of residents stated they certainly or probably would provide abortions, while 65% of residents stated they certainly would not provide abortions. A majority (65%) of residents agreed that first-trimester abortion training should be optional within family practice residency programs. Residents were more likely to agree with inclusion of optional abortion training and with the appropriateness of providing abortions in family practice if their program offered the training.

Hepatitis B status of Hmong patients.

This study was conducted to determine the hepatitis B status, by age, of Hmong patients attending a St. Paul family practice residency clinic. The clinic records of 1585 Hmong patients 4 years of age and older were reviewed for information about hepatitis B status. Those without evidence of previous serologic testing or vaccination were invited to participate in the study by being tested for three hepatitis B virus (HBV) markers-hepatitis B surface antigen (HBsAg), antibody to HBsAg (anti-HBs), and hepatitis B core antibody (anti-HBc); those whose results were positive for HBsAg and anti-HBc were also tested for hepatitis B e antigen (HBeAg) and alanine aminotransferase (ALT). Patients whose results were positive for only anti-HBc had their serologic tests repeated after 3 or more months, and those patients whose results remained positive for only anti-HBc were offered the vaccine and further follow-up serologic tests. Of the 434 total participants, 77 (18 percent) had acute or chronic infection (HBsAg present). The rate of infection was highest-28 percent-in the group of patients 15 to 19 years old. Of 66 patients with positive test results only for anti-HBc, 33 of 36 (92 percent) who had follow-up serologic tests after 3 or more months had the same result again in the absence of intervention. Six of 8 (75 percent) patients with results positive only for anti-HBc who received hepatitis B vaccine subsequently converted to an immune status (anti-HBs positive). For all age groups, the cost of pretesting patients with an unknown HBV status and vaccinating susceptible patients was less than the cost of vaccinating without pretesting. This study, which confirmed previous findings of a high occurrence of hepatitis B virus infection in Hmong refugee communities, found the highest rate of infection to be among adolescents. Prevaccination testing appeared to be a cost-saving procedure for patients whose hepatitis status was unknown.