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A survey conducted by the Wright State University School of Medicine indicates that family practice has become a fully integrated curriculum component in the majority of US medical schools. Results indicate that family practice courses are offered most often as outpatient experiences and are taught by both full-time and volunteer faculty.
The authors describe the development of a curriculum focused on teaching residents in family practice how to recognize and deal with the psychological issues presented by patients and by their own reactions to patients. They describe how teachers in a medical school's divisions of family practice and psychosomatic and liaison psychiatry collaborated to develop an integrated training program and the changes this program effected in the attitudes and understanding of residents. They found that residents in this program shifted their emphasis from a narrow view of traditional medical diagnosis and treatment to a broader psycholgical-biological understanding of patients.
Physician-patient encounters in the home setting have decreased dramatically in the United States in recent years. This has occurred in spite of the continued important role the home environment plays in family health and family illness care. Although decreasing in frequency, home visits are still an important facet of family practice. A survey of family practice residency programs revealed that home visits are being done in most programs and that faculty members have a positive outlook on their importance. Programs were found to vary widely in the types of learning experiences available to residents. There is an apparent need for residency programs to improve their teaching efforts involving family home visiting by establishing objectives, structured curricular time, clinical experience, and protocols consistent with this purpose.
BACKGROUND: No single approach to the regulatory assessment of global consultation competence has been shown to possess the required levels of validity, reliability and feasibility. OBJECTIVE: To evaluate the approach adopted in Kuwait to the regulatory end-point assessment of the global consultation competence of family practice trainees with particular reference to validity, reliability and feasibility. METHODS: Family practice trainees in Kuwait were individually and directly observed for 3 hours in consultation with a minimum of 10 patients by a pair of examiners. Performance was judged against the explicit criteria of consultation competence as contained in the Leicester Assessment Package (LAP). RESULTS: The marks independently allocated by the pairs of examiners to 126 trainees between 1994 and 2001 were within five percentage points on 91% of occasions. A reliability coefficient of 0.82 was achieved when two examiners independently marked candidates consulting with 10 real patients; this rose to 0.95 at the critical 50% pass-fail margin. The main sources of variance contributing to the reliability of marks allocated were candidate performance (42%) and the interaction of candidate performance across cases, i.e., case specificity (30%). The clinical challenges presented by the patients were judged by both examiners to be sufficient to enable performance to be assessed across the seven LAP consultation categories as follows: behaviour and relationship with patients (100% of consultations), interviewing/history taking (100%), record keeping (99%), patient management (99%), problem solving (98%), physical examination (95%), and anticipatory care (86%). Each assessment involved a pair of examiners and lasted approximately 3.5 hours. CONCLUSION: The Kuwait clinical examination achieves high content validity and authenticity as it uses direct observation of performance, validated and explicit criteria against which performance is judged, and real patient challenges. It can discriminate between different levels of consultation performance and satisfies the recognized reliability threshold for regulatory examinations (0.82 vs 0.80). Accordingly, we recommend the use of such an approach in the regulatory end-point assessment of the global consultation competence of trainees in family practice. Such an approach is more valid, and is likely to be more feasible, than simulated surgeries or the short-case OSCE format.
A project of interdisciplinary family medicine education was conducted in which a clinical pharmacist served as a drug therapy consultant-educator in a family practice residency program. The clinical pharmacist provided drug information, advised about drug therapy, taught in formal conferences, prepared and disseminated a drug information bulletin, made rounds with the physicians, provided drug blood level consultation, and conducted a drug utilization review project. The family physicians' attitudes about clinical pharmacy were assessed by interviews before and after the project and by a questionnaire administered after the project. The physicians and the pharmacist in this model were observed to have a greater understanding of the interdisciplinary team practice concept; and an active role for the clinical pharmacist as a teacher and consultant was reinforced.
PURPOSE: Looking for a valid, reliable, and feasible method to collect data on the performances of practicing family physicians, the authors compare the measurement characteristics of a multiple-station examination (MSE) using standardized patients with those of a video assessment of regular consultations in daily practice (practice video assessment, PVA). METHOD: In a cross-sectional study, consultations of 90 family physicians were videotaped both in an MSE and in their daily practices. Peer-observers used a validated instrument (MAAS-Global) to assess the physicians' communication with patients and their medical performances. The physicians were randomly divided into two groups, comparable for demographic characteristics, and half underwent the assessments in reverse order to test for time-order effects. Content validity, criterion validity, reliability, and feasibility of the two methods were compared. RESULTS: Content validity of the PVA was superior to that of the MSE, since the domain of general family practice care was better covered. Observed participants judged the videotaped practice consultations to be "natural," whereas hardly any family physician, after reviewing the videotaped consultations of the MSE, recognized his or her usual working style. Specific criteria made it possible to standardize real practice. Concerning criterion validity, only the medical-performance components of the two methods correlated. No correlation was found for the communication components. Real-practice performance proved to be less influenced by observation than was performance during the MSE. The reliabilities of the two methods, expected to be better in the controlled MSE, were comparable. The administration of the PVA was more flexible, less costly, and better accepted by the family physicians than was that of the MSE. CONCLUSION: Assessment for quality improvement of family physicians' practices by video observation in daily practice is superior to video assessment in a simulated setting using standardized patients.
Over the past several years, increasing emphasis has been placed on geriatric training in family practice residency programs. Because geriatric assessment is an important educational concept, we elected to start an inpatient geriatric assessment program at our community-based military family practice residency. Our experience is outlined here.
BACKGROUND: Electronic mail (email) has the potential to improve communication between physicians and patients. METHODS: We conducted two research studies in a family practice setting: 1) a brief, anonymous patient survey of a convenience sample to determine the number of clinic patients receptive to communicating with their physician via email, and 2) a randomized, controlled pilot study to assess the feasibility of providing health education via email to family practice patients. RESULTS: Sixty-eight percent of patients used email, and the majority of those (80%) were interested in using email to communicate with the clinic. The majority also reported that their email address changed less frequently than their home address (65%, n = 173) or telephone number (68%, n = 181). Forty-two percent were willing to pay an out-of-pocket fee to have email access to their physicians. When evaluating email initiated by the clinic, 26% of otherwise eligible patients could not participate because they lacked email access; those people were more likely to be black and to be insured through Medicaid. Twenty-four subjects agreed to participate, but one-third failed to return the required consent form by mail. All participants who received the intervention emails said they would like to receive health education emails in the future. CONCLUSION: Our survey results show that patients are interested in email communication with the family practice clinic. Our feasibility study also illustrates important challenges in physician-initiated electronic communication. The 'digital divide' - decreased access to electronic technologies in lower income groups - is an ethical concern in the use of email for patient-physician communication.
BACKGROUND AND OBJECTIVES: Domestic violence is an important problem that is often not recognized by physicians. We designed a short instrument for domestic violence screening that could be easily remembered and administered by family physicians. METHODS: In phase one of the study, 160 adult female family practice office patients living with a partner for at least 12 months completed two questionnaires. One questionnaire was the verbal and physical aggression items of the Conflict Tactics Scale (CTS). The other was a new four-item questionnaire that asked respondents how often their partner physically Hurt, Insulted, Threatened with harm, and Screamed at them. These four items make the acronym HITS. In phase two, 99 women, who were self-identified victims of domestic violence, completed the HITS. RESULTS: For phase one, Cronbach's alpha was .80 for the HITS scale. The correlation of HITS and CTS scores was .85. For phase two, the mean HITS scores for office patients and abuse victims were 6.13 and 15.15, respectively. Optimal data analysis revealed that a cut score of 10.5 on the HITS reliably differentiated respondents in the two groups. Using this cut score, 91% of patients and 96% of abuse victims were accurately classified. CONCLUSIONS: The HITS scale showed good internal consistency and concurrent validity with the CTS verbal and physical aggression items. The HITS scale also showed good construct validity in its ability to differentiate family practice patients from abuse victims. The HITS scale is promising as a domestic violence screening mnemonic for family practice physicians and residents.
BACKGROUND: 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. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.
BACKGROUND: The placement of welfare advice services in family practice to assist patients with health-related social and economic issues (e.g. disability benefits) has gathered momentum over the last decade in the UK. This expansion of primary care raises a number of issues for practices hosting these services. OBJECTIVES: To gain the views of advice workers and primary care staff about the issues raised in hosting a welfare advice service across 30 practices in inner city Bradford. METHODS: Views were obtained through focus groups with six advice workers, and primary care staff in 14 practices. A questionnaire was also posted to all practice managers asking their opinions about the service. RESULTS: The focus groups highlighted a number of advantages for patients, including improvements in health and quality of life through increased income and reduced stress from social and economic issues. For practice staff, the service provided a resource to refer patients for welfare advice, reducing the time spent dealing with welfare issues, thereby reducing workload. This was confirmed in the questionnaire to practice managers where 72% said the service had saved time for GPs and reception/office staff. The advice workers raised concerns about the perceived level of commitment to the service from some staff at some practices. Practice staff were particularly concerned about the need for feedback about referrals. CONCLUSION: Providing welfare advice in family practice can act as a valuable resource for primary care staff helping to address their patients health-related social and economic needs.
A randomised trial of assessment by computer was conducted with 180 patients in a family practice clinic. Histories of alcohol, tobacco, and drug use were obtained by computer (n = 60), interview (n = 60), or self completed questionnaire (n = 60). The results of previous research suggest that some patients may provide more accurate information about "sensitive" problems to a computer. No significant differences, however, in levels of consumption or problems were reported for the three methods of assessment. Patients gave differential ratings about the method of assessment, with the computer rated as more interesting but also more mechanical, cold, and impersonal. Although the interview was initially preferred by most, patients who completed the assessment by computer showed a significant increase (13% to 43%) in their preference for the computer after the assessment. The results of our study indicate that patients' acceptance of computers in family practice may be favourably influenced by direct experience with a microcomputer.
The 105-cm flexible sigmoidoscope was studied for the feasibility of its use in a family practice setting in screening for colorectal cancers and polyps. A total of 49 examinations were performed. The average length of colon examined was 71 cm. Insertion to 105 cm was accomplished in 14 patients (29 percent) and exceeded 65 cm in 28 patients (57 percent). No complications of the procedure were encountered. The study indicated that some patients, with no special preparation or medications and no additional discomfort, might benefit by the more thorough screening afforded by 105-cm flexible sigmoidoscope. What is not yet known is the efficacy of large-scale screening for cancers and polyps utilizing the 105-cm flexible sigmoidoscope in the family practice setting.
This study compares the clinical experience of a resident and a faculty member in a model family practice over a three-year period. The resident had 1,565 encounters with 733 patients, and the faculty member had 2,837 encounters with 917 patients. The resident experienced continuity of care by managing his own 300 personal patients for an average of 2.5 visits each, while the faculty member modeled continuity with an average of 3.8 visits for each of 229 personal patients. The resident experienced family care with 33 families having two or more of his personal patients, while the faculty member had 28 such families. Black and white patients of all ages and both sexes, with a wide variety of problems, were seen by both resident and faculty member. Demography was similar except that the resident's patients were younger (mean age 33.3 versus 40.4 years). Their experience parallels that reported elsewhere for practicing family physicians, thereby supporting the model practice as an important component of family medicine residency training.
A modified framework of cost-benefit analysis, including explication of direct, indirect, and intangible costs and benefits, is used to assess the financial impact of a university-affiliated family practice residency program upon a community hospital. During resident year 1978-79 it was found that a community hospital affiliated with the University of Utah Family Practice Residency Program may have experienced a net financial benefit of as much as $243,543 or a net financial cost of as much as $12,537. At the same time, the hospital is likely to have experienced substantial intangible benefits and moderate intangible costs. This approach may have utility in similar settings where community hospitals support family practice resident education.
The issue of differences between university-hospital-based and community-hospital-based family practice residency programs was studied in a network that included five community programs and one large university program. American Board of Family Practice (ABFP) Intraining Examination scores and ABFP board certification scores indicated comparative cognitive knowledge. A graduate follow-up study compared post-residency experience of the graduates of both types of programs. Conclusions from the study showed little difference between subjects trained in the two types of programs. Differences in examination scores were not significant. Small differences in graduate perception of adequacy of preparation for content areas and in postresidency practice characteristics seemed equally insignificant, but were not amenable to statistical testing.
491 consecutive adult patients who consulted their family physician for routine medical problems completed a five item screening questionnaire for alcoholism and a checklist of 12 commonly occurring symptoms. More than 11% showed definite evidence of alcoholism while another 6% showed probable evidence. Review of the medical record for that visit revealed that a large proportion of the alcoholics detected through this method were not diagnosed as such nor was alcohol charted as a significant factor in their medical problems. Patients who reported common symptoms such as blackouts, tremors, temper outbursts, chest pain, unsteadiness, loss of appetite, vomiting, sadness and "stomach pain" had significantly higher rates of alcoholism than those who did not report these symptoms. In order to detect alcoholism in family practice, it may be useful to routinely ask a few inoffensive questions to increase significantly the detection rate.
The Military Unique Curricula (MUC) was published in 1988 as a guideline for instruction at military residencies in military-specific topics. Questionnaires were sent to 464 military family practice residency graduates from 1987-1990 to evaluate the degree of implementation of the MUC and attitudes and logistical factors relevant to military medicine instruction in military family practice residencies. Analysis reveals a range of opinions regarding the importance of military medicine and the amount of instruction on military medicine topics offered among programs. The total number of topics offered for instruction was positively correlated (p < 0.05) with the time available to teach the material, a perception that the material would not be best learned at the Combat Casualty Care Course, and the presence of a specific military medicine curriculum within the residency. This survey provides baseline information for future evaluation of the influence of MUC on military medicine instruction in residency programs. Suggestions are offered to improve instruction on military medicine topics in military family practice residencies.