Funding of patient care, education, and research in family practice.
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Family Practice↗
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The relationship between management practices and financing of family practice residency training programs.
This paper summarizes almost ten years of investigation in the area of financing of Family Practice Residency Training Programs. The author has been a co-principal investigator in this effort with responsibility for administration of two national surveys to study financing of the programs.
Education, Medical, Graduate↗
The pond is wider than you think! Problems encountered when searching family practice literature.
OBJECTIVE: To explain differences in the results of literature searches in British general practice and North American family practice or family medicine. DESIGN: Comparative literature search. SETTING: The Department of Family and Community Medicine at the University of Toronto in Ontario. METHOD: Literature searches on MEDLINE demonstrated that certain search strategies ignored certain key words, depending on the search engine and the search terms chosen. Literature searches using the key words "general practice," "family practice," and "family medicine" combined with the topics "depression" and then "otitis media" were conducted in MEDLINE using four different Web-based search engines: Ovid, HealthGate, PubMed, and Internet Grateful Med. MAIN OUTCOME MEASURES: The number of MEDLINE references retrieved for both topics when searched with each of the three key words, "general practice," "family practice," and "family medicine" using each of the four search engines. RESULTS: For each topic, each search yielded very different articles. Some search engines did a better job of matching the term "general practice" to the terms "family medicine" and "family practice," and thus improved retrieval. The problem of language use extends to the variable use of terminology and differences in spelling between British and American English. CONCLUSION: We need to heighten awareness of literature search problems and the potential for duplication of research effort when some of the literature is ignored, and to suggest ways to overcome the deficiencies of the various search engines.
Depression↗
Physician practice styles and patient outcomes: differences between family practice and general internal medicine.
OBJECTIVES: This study compared patient health status, patient satisfaction, and physician practice style between family practice and internal medicine. METHODS: New adult patients (n = 509) were prospectively and randomly assigned to family practice or internal medicine clinics at a university medical center and followed for 1 year of care. Practice styles were characterized by the Davis Observation Code. Self-reported health status (Medical Outcomes Study, Short Form-36) and patient satisfaction also were measured. RESULTS: There were no significantly different changes in self-reported health status or patient satisfaction between family practice and internal medicine physicians during the course of the study. Family practice initial encounters, however, were characterized by a style placing greater relative emphasis on health behavior and counseling, whereas internists used a more technical style. Improved health status scores after treatment were predicted by a practice style emphasis on counseling, whereas improvements in patient satisfaction scores were predicted by a style of care stressing patient activation. Although this is the first known randomized trial studying this issue, the conclusions are limited by a 38% loss of patients from enrollment to care and a loss of 18% at the 1-year follow-up evaluation. CONCLUSIONS: There were significant differences in practice styles between family physicians and internists; however, it was the physician's behavior, not specialty per se, that affected patient outcomes. A practice style emphasizing psychosocial aspects of care was predictive of improvements in patient health status, whereas a practice style emphasizing patient activation was predictive of improvements in patient satisfaction.
Adult↗
Practice-based preceptoral residency training in family practice.
BACKGROUND AND OBJECTIVES: Highly specific accreditation requirements have led to a uniform approach in US family practice continuity training. In this paper, we describe an experiment in practice-based preceptoral continuity training. METHODS: We assessed the impact of assigning a resident to a private faculty practice for the second- and third-year levels of family practice continuity training. Data analysis included comparisons of practice demographics, clinical content, training costs, and resident assessment of training quality. RESULTS: The preceptoral resident practice better approximated community demographic patterns than did the established residency practice. However, the preceptoral resident practice had relatively fewer visits for hypertension and diabetes mellitus than did the established residency, preceptoral site faculty, and National Ambulatory Medical Care Survey practices. Resident training at the preceptoral site resulted in a positive training expense differential of $69,300 calculated on an annual per third-year resident basis. The preceptoral resident expressed high levels of satisfaction with the quality of family practice center training. CONCLUSIONS: Practice-based preceptoral continuity training in family practice appears feasible in terms of clinical content exposure and may offer substantial financial advantages. Important questions remain, particularly about the quality of teaching and supervision in a preceptoral training model.
Family Practice↗
Validity of two psychological screening measures in family practice: Personal Inventory and Family APGAR.
To determine the level of accuracy with which the Personal Inventory and Family APGAR identify patients with psychological distress, the two instruments were administered to patients new to a family practice clinic. Eighteen months later, the following clinical variables were recorded by chart audit: number of physician visits, number of chronic and acute illnesses or conditions diagnosed, and presence of psychological symptoms. A high frequency of psychological symptoms was observed in the clinical sample; depression, anxiety, marital problems, and chemical dependency were most frequently seen. Statistically significant differences were observed between the mean scores for symptomatic and nonsymptomatic patients on both the Personal Inventory and Family APGAR. Cutting scores established for each instrument allowed for the accurate classification of 83 percent of symptomatic patients by the Personal Inventory and 68 percent of symptomatic patients by the Family APGAR. Substantial gains in screening accuracy occurred when both measures were administered and when a "symptomatic" score on either instrument was considered suggestive of psychological distress. Although individuals with "symptomatic" scores attended the clinic more frequently than those nonsymptomatic by test, differences were not statistically significant. The results support the use of the Personal Inventory and the adjunctive use of the Family APGAR.
Adult↗
A community collaborative practice experience between Med/Peds and family practice.
PURPOSE: The medical literature has followed educational outcomes of Medicine-Pediatric (Med/Peds) physicians, but limited studies exist as to clinical outcomes for these combined specialty physicians. Although a variety of practice environments are available for a growing number of Med/Peds physicians, a collaborative practice setting with family physicians may optimize the Med/Peds practice potential. This study investigates clinical practice outcomes and utilization efficiencies of collaborative Med/Peds family practice physicians within a community, which should provide an effective model in a growing managed care environment. PATIENTS AND METHODS: Two collaborative practice settings in a moderate size Midwest community were analyzed with respect to patient demographics and utilization scores provided by a practice management group and a nationally based health care network. Current Procedural Terminology (CPT) coding was used to follow demographic trends for over 45,000 patient visits for 1 year. Efficiency ratings (Z-scores) were used over the same year for over 6,000 health care network patient visits to 10 collaborative practice-based physicians, which were then compared to 141,101 community family practice patient encounters, 26,617 general internist patient encounters, and 29,995 patient encounters to pediatricians for utilization trends. RESULTS: Med/Peds and Family Practice patient care data reflected nearly identical patient demographics between specialties with only a few exceptions. Med/Peds physicians cared for three times the total number of children less than 2 years old. Med/Peds physicians experienced a higher complexity of illness, in part due to a 40% increase in internal referrals from family practice colleagues in the ambulatory care setting, while maintaining a third of the proportion of outpatient referrals. Cost-effective interoffice utilization was still maintained, supported by a more optimal efficiency rating for Med/Peds physicians compared to collaborative family practice colleagues. Inpatient efficiency was demonstrated for Med/Peds specialists even though a threefold increase in hospitalizations was observed, in part resulting from physicians within these collaborative practices arranging all newborn nursery and pediatric admissions be covered by Med/Peds physicians. Both collaborative primary care specialists demonstrated more cost-effective overall practice utilization scores when compared to community-based primary care specialists. CONCLUSIONS: Med/Peds physicians in this study have been trained to provide cost-effective patient care in both outpatient and inpatient settings. Decreased outside referrals by collaborative family practice physicians through utilization of Med/Peds colleagues serves to optimize practice economy by eliminating the threat of competition that exists among community-based generalists. Such a model helps to control an overused referral system to subspecialists.
Community Health Services↗
Provisions of the Americans with Disabilities Act and the development of essential job functions for family practice residents.
BACKGROUND: Family practice residency program directors and faculty are frequently faced with residents who sustain a temporary illness or become disabled during residency. In addition, disabled applicants are seeking positions in medical schools and residencies. Program directors and faculty have an obligation to understand the laws that apply to disability and illness to develop fair and workable policies within their programs. This article explores the provisions of the Americans With Disabilities Act that apply to family practice residency programs and residents with illness and disability. One of the key requirements for dealing with resident illness or disability is the development of essential job functions. We present a strategy to enable individual residency programs to develop a list of essential job requirements for family practice residents. An example of essential job requirements is given.
Persons with Disabilities↗
Geriatric medicine curriculum consultations for family practice residency programs: american academy of family physicians residency assistance program/hartford geriatrics initiative.
Increasing the quality and quantity of geriatric medicine training for family practice residents is a particular challenge for community-based programs. These programs have an average of only seven full-time equivalent physician faculty. This report summarizes results of the Residency Assistance Program/Hartford Geriatric Initiative (RAP/HGI) geriatric medicine curriculum consultations for family practice (FP) residency programs conducted from 1996 to 2001. This project was developed as part of the RAP in family practice. Ten experienced FP educators were selected and trained as special consultants. Between 1996 and 2001, 39 FP residency programs participated in the 1- to 4-day RAP/HGI consultations. The programs were diverse in size and location. The consultations reached 308 family practice residency faculty members involved in training 807 residents. Program evaluations of the consultants were uniformly in the very good to excellent range, with a mean rating of 4.6 (5-point scale, with 5 indicating excellent). At the end of the initial consultation visit, the residency program faculty and the consultant developed short-term goals for geriatrics program development. Eighty-five percent (33/39) of the programs submitted their curriculum goals in writing. The mean number of goals per program was 4.8 (range = 3-11). Of the 33 programs with written goals, follow-up was documented for 29 programs. Seventy-nine percent of the programs' self-defined educational goals were met during the 6 to 12 months of follow-up (range 50-100%). Ten of the programs implemented all of their educational goals. The RAP/HGI project demonstrated that achievable geriatric medicine curriculum improvements could occur as part of an onsite consultation process.
Connecticut↗
Individual and contextual factors related to family practice residents' assessment and counseling for tobacco cessation.
BACKGROUND: Tobacco use is the chief avoidable cause of death in the United States. Physicians, however, are not routinely assessing this risk and providing counseling for risk reduction. This study examines tobacco cessation counseling practices among family practice residents and explores the determinants of residents' smoking-counseling behaviors and counseling duration. METHODS: One hundred ten family practice residents (response rate = 93.2%) from four Texas residency training programs completed a survey designed to assess tobacco cessation counseling practices. RESULTS: A high proportion of residents reported that they usually or always assessed tobacco use (59.3%) and advised their patients to quit smoking (80.9%), with a lower proportion reporting specific counseling behaviors (7.3% - 21.9%), referrals (1.8%), or follow-up visits (1.8%). Year of residency, perceived effectiveness, and the interaction between perceived effectiveness and residency year were significantly associated with number of counseling behaviors, and year of residency and perceived effectiveness were significantly associated with counseling duration. CONCLUSIONS: Faculty physicians should assist residents to implement the Public Health Service-sponsored clinical practice guideline for tobacco control. There is a need to increase behavioral skills and perceived effectiveness for assessing and counseling smokers among first-year residents.
Counseling↗
The use of the family APGAR in screening for family dysfunction in a family practice center.
The Family APGAR questionnaire was used to determine the prevalence of self-reported family dysfunction present in patients who attended a family practice center, to determine whether knowledge of the Family APGAR score increased the frequency with which family physicians evaluated family functioning and diagnosed family dysfunction, and to determine whether certain psychosomatic complaints associated with family dysfunction were more common in a group of patients with a Family APGAR score of less than 6. To achieve these purposes, all patients entering the center were asked to fill out a Family APGAR questionnaire during the month of March 1984. Physicians learned of the results in a randomly selected one half of all cases. A chart review was conducted one month later. Twenty-four percent of patients reported family dysfunction (APGAR less than 6). Knowledge of the APGAR score did not increase the frequency with which physicians evaluated family function (20 percent known vs 17 percent unknown) or diagnosed family dysfunction (6.3 percent known vs 6.4 percent unknown). Patients with self-reported family dysfunction as defined by the Family APGAR did not have more psychosomatic complaints noted in their charts than patients without self-reported family dysfunction. Family dysfunction is a common problem in family practice patients, it is recorded infrequently in patients' charts, and knowledge of the results of a screening device does not increase the frequency with which family dysfunction is noticed.
False Negative Reactions↗
Educational resource sharing and collaborative training in family practice and internal medicine. A statement from the American Boards of Internal Medicine and Family Practice.
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Family Practice↗
Does family practice at residency teaching sites reflect community practice?
BACKGROUND: Family medicine has aspired to train residents and conduct research in settings that closely resemble community practice. The purpose of this study was to compare the patient characteristics of the ambulatory teaching centers of a consortium of seven community-based university-affiliated family practice residency programs in northeast Ohio with the National Ambulatory Medical Care Survey (NAMCS) results for family physicians (FPs) and general practitioners (GPs). METHODS: Ninety-eight faculty and resident physicians at the residency training site of the Northeastern Ohio Universities College of Medicine collected data on all ambulatory patient visits (N = 1498) for one randomly chosen week between July 1, 1991, and June 30, 1992. We compared these data with patient visits reported in the 1990 NAMCS for FPs and GPs. RESULTS: The residency training sites saw slightly more children, women, blacks, and Medicare and Medicaid patients. The most common reason for an office visit in both populations was an undifferentiated symptom. Fifteen of the top 20 "reason for visit" codes were identical, as were 14 of the top 20 diagnoses. More preventive and therapeutic services were offered or performed at our residency training sites but fewer diagnostic services were performed. There were fewer consultations requested at our residency training sites but similar hospitalization rates for patients. The mean duration of visit differed by only 1 minute. CONCLUSIONS: The residency training sites of the Northeastern Ohio Universities College of Medicine provide patient care opportunities similar to those found in a national survey of family and general practitioners.
Adolescent↗
Discussions of "code status" on a family practice teaching ward: what barriers do family physicians face?
BACKGROUND: Patients want physicians to ascertain their wishes related to resuscitation, yet such discussions of "code status" are often delayed in the hospital setting, which compromises patient autonomy. Few studies have examined family physicians' views on this topic. Our objectives were to explore the experiences of family physicians and family practice residents in establishing code status with their patients who had been admitted to hospital and to identify barriers to these discussions. METHODS: Semistructured, in-depth interviews were conducted with 5 family physicians and 5 family practice residents admitting patients to a family practice teaching ward in a university-affiliated urban tertiary care hospital. Interview transcripts were analysed inductively, and grounded theory was used to identify conceptual categories and recurring themes. Key findings were validated by means of member checking with participants, consensus meetings of the research team and consultation with qualitative researchers. RESULTS: Barriers to code-status discussions included personal discomfort with confronting mortality, fear of damaging the doctor-patient relationship or harming the patient by raising the topic of death, limited time to establish trust, and difficulty in managing complex family dynamics. In spite of these challenges, family physicians and residents viewed discussions of resuscitation as a significant part of their role. INTERPRETATION: Family physicians and residents need to develop personal awareness about difficulties in confronting mortality, enhance their communication strategies for broaching the topic of code status in the context of a trusting doctor-patient relationship and sharpen their skills in understanding and managing family dynamics related to end-of-life decisions. Awareness of the barriers to code-status discussions can inform research, education and hospital policy. Consultation with patients is needed to develop effective communication strategies.
Attitude to Death↗
Longitudinal teaching of obstetrics in family practice residency programs.
Family practice residency programs teach obstetrics using both hospital service block rotations and longitudinal management of family practice center pregnant patients. A national survey was conducted to identify characteristics and outcomes of residencies using family physicians and/or obstetricians as preceptors for the longitudinal teaching of obstetrics. Obstetricians were used as preceptors in both outpatient and delivery room settings in 18% of residencies. Family physicians were used in the outpatient setting and obstetricians in the delivery room in 27% of programs. The 37% of programs using family physician faculty as preceptors in both outpatient and delivery room settings differed from other programs in four significant ways: they were most likely to be medical school or military residency programs; they were most likely to be located in the north central and mountain states; they reported greater general satisfaction with their preceptors; and more of their graduates practiced obstetrics after residency.
Ambulatory Care Facilities↗
Family practice in Canada.
Family practice in Canada is significantly different in many ways from practice in the United States and is similar in others. This article describes Canada's comprehensive, government-controlled health care system, in which patients have free access to care, and most physicians are still paid on a fee-for-service basis. The status of medical manpower in Canada and medical education for future family physicians in the 16 Canadian medical schools are described. The multiple roles of the College of Family Physicians of Canada are outlined. The article concludes with a description of the nature of family practice in Canada, comparing it with the United States.
Canada↗
Postgraduate education for rural family practice. Vision and recommendations for the new millenium. Working Group on Postgraduate Education for Rural Family Practice.
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Canada↗
A comparison of the patients and practices of recent graduates of family practice and general internal medicine residency programs.
This study compares the characteristics of the practices and patients of recent graduates of family practice and general internal medicine residency programs. National samples of 104 family physicians and 134 general internists completed questionnaires and provided log-diary data for more than 7,500 office visits and 1,100 hospitalized patients. Family physicians and general internists were generally similar in demographic and practice characteristics, though family physicians were more likely to have entered office-based practice (90% versus 70%). Among office-based physicians, family physicians saw more patients per week in ambulatory settings (117.3 versus 74.6), whereas general internists had more patients in the hospital (6.45 versus 3.81) and provided more hospital consultations per week (2.74 versus 0.45). Family physicians practiced in smaller communities and were more likely to practice on Saturday mornings, to accept walk-in patients, and to schedule appointments for new patients within 1 week. Both specialties functioned as first-contact generalists for at least 95% of office encounters. Although pediatrics and obstetrics are practiced only by family physicians and general internists see proportionately more older patients, within specific age groups the patients of general internists and family physicians were similar in terms of their main health problems, functional status, and diagnoses.
Data Collection↗