Background and Objectives: This study sought to determine whether Medicaid patients with a regular source of care (RSOC) are less likely to be hospitalized, either for all conditions or for ambulatory care sensitive conditions (ACSCs), than those without an RSOC.

Methods: This population-based survey study examined Delaware Medicaid patients ages 0-64 over a 1-year period from September 1992 to August 1993 (n=22,862). Patients who had made more than 50% of their physician office visits to the same provider group were considered to have an RSOC. The probability of hospitalization for all conditions and for ACSCs was compared for persons with and without an RSOC.

Results: Eighty-one percent of Medicaid clients had an RSOC, 75% of whom were primary care physicians. Persons with an RSOC were not less likely than those without an RSOC to be hospitalized for any condition (15% versus 14.6%) or for ACSCs (3.4% versus 3.2%). The results were not substantially different for persons who used primary care physicians as their RSOC.

Conclusions: Having an RSOC is not associated with a lower likelihood of hospitalization for the Medicaid population, either for all conditions or for ACSCs. While providing access to care may have other positive benefits, simply providing Medicaid patients with an RSOC is unlikely to result in a short-term reduction in hospital admissions.

Background: Recognition of depression in primary care is both important and difficult. To study recognition of depression, we monitored care delivered to new adult patients randomly assigned to primary care providers.

Methods: At study entry, 508 patients completed the Beck Depression Inventory (BDI) and the Medical Outcomes Study Short-form Health Survey-36 (SF-36), a measure of health status. Chart notes were reviewed at the end of 1 year.

Results: Only 36 of 130 patients with elevated BDI scores less than or equal to 9 (moderate-to-severe depression) were noted as depressed on the chart. Patient characteristics predicting chart notation of depression included BDI scores, health status, gender, and education. When controlling for these factors, neither age nor race were statistically significant in the prediction of the recognition of depression. Female patients were more likely to be diagnosed as depressed than men with comparable BDI and SF-36 scores. Greater patient education was associated with enhanced likelihood of diagnosis of depression. Both BDI scores and health status were important predictors of diagnosis of depression. All SF-36 subscales correlated highly with BDI scores, suggesting that these measures may lack adequate discriminant validity.

Conclusions: Identifying diagnostic tendencies may help primary care providers improve detection of depression, a critical first step toward effective management.

Background and Objectives: Anxiety and depression are highly prevalent and underdiagnosed in primary care. This study tested the seven-item Duke Anxiety-Depression Scale (DUKE-AD) in primary care adult patients as a screener for anxiety and depression as defined by the Diagnostic and Statistical Manual of Mental Disorders (DSM-III-R).

Methods: Receiver operating characteristic curves (ROC) and odds ratios were used to test screener accuracy, and sensitivities and specificities were used to test screener efficiency in patients with anxiety and/or depression.

Results: In 481 patients, the ROC area for patients with major anxiety disorders (panic disorder, agoraphobia, or generalized anxiety) was 72.3%. The ROC area for major depressive disorders (major depressive disorder and/or dysthymia) was 78.3%, and the ROC area for both major anxiety and/or depressive disorders was 76.2%. Odds ratios for these same groups after controlling for sociodemographic factors were 1.043, 1.057, and 1.053, respectively. Sensitivities and specificities for these groups at the DUKE-AD score cutoff point of >30 on a 0-100 scale were 71.4% and 59.2%, 81.8% and 63.6%, and 73.9% and 66.1%, respectively.

Conclusions: The DUKE-AD is a brief, easily scored questionnaire that serves as a valid screener for DSM-III-R anxiety and depression in the primary care setting.

Background: Many military physicians interrupt their training to serve in the position of general medical officer (GMO) after completing their first year of postgraduate medical education. This study compares American Board of Family Practice In-training Examination (ITE) scores of military family practice residents who received continuous training (CFP residents) with those who did GMO tours (GMO residents).

Methods: Historical cohorts of CFP and GMO residents from Army and Navy family practice residencies were compared. The dependent measures were their ITE scores in each year of training. Paired data were analyzed using the Student's t test.

Results: There were no significant differences in composite or clinical problem set scores between GMO and CFP resident groups. Power to detect a true difference between the groups was .74.

Conclusions: Interruption in residency training is not associated with a significant change in the returning resident's ITE scores.

Background and Objectives: Previous descriptions of the Advanced Life Support in Obstetrics (ALSO) course have indicated increases in physician comfort in managing obstetric emergencies and in their intentions to continue offering maternity care after taking the course. No previous studies have been done about the educational outcomes of the ALSO course on family practice residents. This study compared residents' pre- and post-ALSO course confidence to manage obstetrical emergencies and their intention to provide maternity care when they enter practice.

Methods: A self-selected group of 55 family practice residents completed questionnaires before and after ALSO training. The questionnaire was designed to measure confidence, using Bandura's model of self efficacy, and future intention, using Ajzen's Theory of Planned Behavior.

Results: Residents' confidence in their abilities to manage obstetrical emergencies increased significantly after the ALSO course. Residents' intent to provide maternity care when the residents enter practice did not change.

Conclusions: The ALSO course is a valuable teaching intervention that can improve family practice residents' perceived self-confidence in managing obstetric emergencies. The study had sufficient power to detect a moderate effect size of the ALSO course on resident intention to provide maternity care but did not do so.

Background: Faculty development fellowship programs provide avenues for physicians to develop careers in academic medicine. However, the long-term impact of these programs has not been evaluated. This paper examines the impact of an 18-month substance abuse faculty development fellowship administered by the Society of Teachers of Family Medicine (STFM) 7 years after the fellowship's completion.

Methods: Fellows were interviewed by telephone. Their CVs were examined to assess how their present substance abuse teaching, clinical, research, administrative, scholarly, and networking activities compared with those prior to the fellowship.

Results: Initially, fellows contributed modules to an STFM publication and increased substance abuse teaching in their home institutions. Seven years later, fellows reported increased activity in substance abuse teaching, clinical, administrative, and research activities over those prior to the fellowship and attributed these increases to the fellowship. Fellows' CVs reflected increased publications, presentations, and networking activities with each other, including the creation of the STFM Group on Substance Abuse.

Conclusions: In a 7-year follow-up, STFM's substance abuse fellowship program met its original goals, strengthened the academic and professional achievements of the fellows, and fostered the development of several fellows as leaders within the substance abuse field.

Background and Objectives: The Harbor-UCLA Family Practice Residency Program has offered a year-long primary care continuity clinic experience to first-year obstetrics-gynecology (OB-GYN) residents since July 1994. This paper describes the teaching programs and compares the experience of the OB-GYN residents to that of family practice (FP) residents in the same clinic site.

Methods: OB-GYN residents worked in the family medicine teaching clinic for a half day each week for the entire year. The teaching program was evaluated with a questionnaire and interviews of OB-GYN residents to obtain their opinions on the value of this teaching modality. A review of clinic schedules and medical records compared the practice profiles of six OB-GYN residents with six matched FP residents.

Results: Five out of six OB-GYN residents felt that the educational objective of improving primary care skills was achieved. Half of them were pleased about their relationships with the family medicine faculty; the remainder reported being treated as second-class citizens. Patient volume and the diagnosis encountered were similar between the OB-GYN residents and the FP residents.

Conclusions: Evaluation of the primary care continuity clinic experience for OB-GYN residents through questionnaires, interviews, and medical records analysis revealed the acceptability, feasibility, and appropriateness of this teaching program for OB-GYN residents. However, not all OB-GYN residents were happy about their relationships with the family medicine faculty. The long-term effectiveness of the experience needs further study.

Background and Objectives: Part-time faculty development fellowship programs have trained large numbers of new physician faculty for family medicine education programs. This study reviews data from three part-time fellowship programs to determine how well the programs train new faculty and the academic success of fellowship graduates.

Methods: Part-time fellowship programs at Michigan State University, the University of North Carolina, and the Faculty Development Center in Waco, Tex, sent written surveys to graduates as part of routine follow-up studies. Graduates were asked to report their current status in academic medicine, how they spend their time, measures of academic productivity, and assessments of how well their training prepared them for their current academic positions. Data were compiled at each institution and sent to Michigan State University for analysis.

Results: The majority of graduates (76%) have remained in their academic positions, and half (49%) teach in medically underserved settings. Graduates report high levels of satisfaction with the training they received. Thirty-two percent of graduates have published peer-reviewed articles, and almost 50% have presented at peer-reviewed meetings.

Conclusions: Part-time fellowship programs have been successful at training and retaining large numbers of new faculty for family medicine.

Background: For medical students and residency programs alike, the residency application process is time-consuming. This paper examines one program's experience with a computerized system designed by the Association of American Medical Colleges (AAMC) to simplify and standardize the filing and receipt of applications over the Internet.

Methods: A large-scale pilot test of the Electronic Residency Application Service (ERAS) was implemented in 1995-1996 for applicants to first-year residency positions in OB-GYN. Each student completed the computerized application, which was transmitted, along with other documents, to student-specified programs by the dean's office via the AAMC "electronic post office." ERAS will be extended to family practice residencies in 1997-1998.

Results and Conclusions: A major advantage of ERAS to residency programs is that materials were received in a well-organized, complete, and consistent format. Built-in filters allow grouping of applicants according to various criteria. Opening envelopes and filing documents is no longer necessary. Each student completes one application, and faculty write one letter of recommendation per student. Disadvantages of the 1995-1996 system related to the software, which had an inflexible interface and did not allow a spreadsheet view of the database. Personal statements and recommendation letters were often sent as unformatted ASCII text and were difficult to read. Deans' offices reported problems scanning documents such as transcripts and photographs. These problems led to resubmission of materials and receipt of duplicate copies. With the standard application format, ASCII-style personal statements and "generic" recommendation letters caused applicants to lose individuality. Specific recommendations to the AAMC for improving ERAS include providing a spreadsheet view, allowing students and faculty to write personal statements and letters in standard word processing formats, and allowing faculty to send unique letters to specific residency programs.