Background and Objectives: This study assessed the feasibility, reliability, and acceptability of video teleconference precepting of residents practicing in rural sites.

Methods: Precepting encounters were conducted between faculty at our home-base family practice center and third-year residents at a rural site. Full audio and video teleconferencing equipment was used; data was transmitted by fractional T1 lines. Residents and faculty recorded patient demographics, rated the technical quality of the encounter, and noted equipment problems during encounters.

Results: Video teleconferencing was used for 137 patient encounters, which was 10% of all encounters. The self-reported technical quality of the encounter was acceptable (all 4 dimensions of quality rated a median score of 4 out of 5). Minor transmission or equipment problems were noted 20% of the time by residents. Use of teleconferencing diminished considerably over the 6-month period of the study. Most cases precepted by teleconferencing involved uncomplicated acute illnesses.

Conclusions: Telemedicine precepting was technically feasible, generally reliable, and initially acceptable to the third-year residents. However, the cases precepted were mostly acute illnesses, and use of telemedicine for precepting diminished over time.

Special Articles: Telemedicine Precepting
(Fam Med 1999;31(4):239-43.)

What Should We Be Teaching Residents About Behavioral Science? Opinions of Practicing Family Physicians
Kim Marvel, PhD; Gregory Major, MD

Background and Objectives: A behavioral science curriculum in family practice residency education encompasses a wide range of topics. Time limitations reduce the number of topics that can be emphasized. This study presents the opinions of practicing family physicians regarding the prioritization of behavioral science topics for residency education.

Methods: We mailed a questionnaire to 633 practicing family physicians. Respondents provided demographic data and rated 28 behavioral science topics according to priority to be given in residency education.

Results: A total of 447 questionnaires were returned, for a response rate of 71%. On a 4-point scale, the average ratings of the 28 topics ranged from 3.79 (depression) to 2.40 (enuresis/encopresis). Female physicians and physicians with a behaviorist in their practice provided significantly higher overall average ratings.

Conclusions: Practicing family physicians identify specific behavioral science topics to be given high priority during residency education. The list of prioritized topics may provide a useful guide to help family medicine educators decide which topics to emphasize in the behavioral science curriculum.

Education Research and Methods
(Fam Med 1999;31(4):248-51.)

Evaluating Residency Applicants: Stable Values in a Changing Market
Charles Travis, MD; Christine A. Taylor, PhD; Harry E. Mayhew, MD

Background and Objectives: A 1994 study found significant differences in the way family practice and OB-GYN residency directors ranked the importance of components of the residency application package. Family practice residency directors favored qualitative measures (dean’s letter, personal statement), and OB-GYN residency directors favored quantitative measures (transcripts, National Board of Medical Examiners score). The authors of the 1994 study hypothesized that the differences could be attributed to specialty competitiveness and philosophy. Our study reexamined family practice rankings of these same application components to determine if the programs, with increased competition for residency positions, had changed their values.

Methods: We surveyed all Accreditation Council for Graduate Medical Education-approved residency directors, using the core questions from the 1994 study, plus 2 additional questions.

Results: The component rankings in 1997 were virtually identical to the rankings in 1994. The new variables, computed to identify competitiveness, failed to elicit any meaningful or consistent differences.

Conclusions: Program directors have remained relatively stable in favoring the qualitative aspects of the application package, ranking the dean’s letter and personal statement consistently in the top 3 positions. This stability is found across time and independent of success in the National Resident Matching Program and number of US graduate applicants. Residency directors have not increased their reliance on quantitative measures.

Educational Methods and Research
(Fam Med 1999;31(4):252-6.)


Primary Care Physicians’ Training and Their Community Involvement
Beat D. Steiner, MD, MPH; Donald E. Pathman, MD, MPH; Brett Jones, MA; Eric S. Williams, PhD; Toija Riggins, PhD

Background and Objectives: Physicians who incorporate a community perspective into their clinical practice can provide more effective care, but little is known about the type of training that helps physicians include this perspective. This study examines associations between physicians’ current level of involvement in their communities and a range of prior educational experiences.

Methods: We obtained data from 247 recently graduated primary care physicians through a nationwide mail survey. Physicians described their community-related training experiences during medical school and residency. They also described their current involvement in each of 4 domains of community work. Associations between different training experiences and physicians’ current community involvement were examined.

Results: Subjects generally reported limited community-related training. Physicians who did receive training in content relevant to a given community domain were significantly more involved in that domain as practicing physicians. Rotating in rural locations and having a mentor active in the community also were associated with greater current community involvement.

Conclusions: These data provide evidence that formal training experiences can influence how actively physicians will later interact with their communities. We should provide medical students and residents with educational content in all 4 domains of community work, place them in carefully selected locations, and arrange mentor relationships.

Educational Research and Methods
(Fam Med 1999;31(4):257-62.)

A Measure of Medical Instructional Quality in Ambulatory Settings: The MedIQ
Paul A. James, MD; Jason W. Osborne, PhD

Background and Objectives: Concerns exist about the quality of medical student training outside the academic medical center. Yet, measures of this quality are lacking. This study introduces an instrument to measure instructional activities in primary care settings, based on a learner-centered model. The study also examines the instrument’s ability to predict specific learner outcomes.

Methods: The MedIQ is a 25-item instrument designed to assess preceptor activities, environmental interactions, learning opportunities, and learner involvement in patient care. The MedIQ was administered in third-year generalist clerkships at one medical school, and the results were compared to extant measures of precepting effectiveness, student grades, specialty choice, and National Board of Medical Examiners scores.

Results: The results revealed strong reliability for all scales, moderate construct validity, and weak criterion-related validity. Additionally, some scores predicted specialty choice.

Conclusions: The MedIQ is a promising measure of instructional quality in ambulatory medical settings.

Educational Research and Methods
(Fam Med 1999;31(4):263-9.)

Effect of a Reorganized After-hours Family Practice Service on Frequent Attenders
Peter Vedsted, MD; Frede Olesen, MD, PhD

Background: A governmental reorganization of the after-hours general practice service in Denmark was launched in January 1992. The biggest change was the introduction of mandatory county-wide telephone triage systems staffed by general practitioners. This study assesses the effect of this reorganization on the use of services by frequent attenders (FAs).

Methods: From 1990 to 1994, methods of contact and annual costs per attender were analyzed in an ecological time-trend study based on aggregated administrative data collected from the database of the Public Health Insurance, Aarhus County, Denmark (600,000 inhabitants). The study only included attenders ages 18 and over. FAs were defined as the group that, within each calendar year (12 months), had 4 or more contacts with the after-hours family practice service.

Results: FAs made up 9.5% of the attenders and accounted for more than 40% of the contacts and the aggregate costs. The effect of the reorganization was a 12% decrease in the number of attenders, a 16% decrease in the number of contacts, and a 29% decrease in the costs. Reorganization had a significantly bigger effect on FA attendance than on non-FA attendance, and more than half of the overall reduction in use of services could be ascribed to changes in FA behavior.

Conclusions: The reorganization of the after-hours service produced a significant fall in attendance and costs, especially with respect to adult FAs.

Clinical Research and Methods
(Fam Med 1999;31(4):270-5.)

An Unusually High Prevalence of Asthma in Ethiopian Immigrants to Israel
Reena Rosenberg, MD; Shlomo Vinker, MD; Hava Zakut, MD; Felix Kizner, MD; Sasson Nakar, MD; Eliezer Kitai, MD

Background and Objectives: The past 20 years have seen a large immigration of Ethiopian Jews to Israel, primarily in 2 airlifts, one in 1984–1985 and one in 1991. Infectious and parasitic diseases were the dominant health problems in the early years. Recently, we noticed changing health patterns in this population, particularly an increase in clinic visits for asthma, which contrasted with asthma rates of 2.5% reported among Ethiopian Jews at the time of immigration to Israel. This study evaluated the prevalence and characteristics of asthma in a population of Jews of Ethiopian origin who had been in Israel for 8–17 years.

Methods: We audited 302 files of adult patients of Ethiopian origin and 604 files of age- and gender-matched patients of non-Ethiopian origin. Each file was reviewed by 2 physicians. Asthma was defined by published clinical criteria as found in the patient file. Data on allergies and eosinophilia were collected as well.

Results: The average age of the 2 groups of asthmatics was 44.1 ± 16.2 and 42.4 ± 20.7 years, respectively. The prevalence of asthma in the patients of Ethiopian origin was 51/302 (17%), compared with 35/604 (5.8%) in the control group. Thirty-three percent of the Ethiopian asthmatics and 37% of the control group suffered from various allergic diseases. Among the patients of Ethiopian origin, the prevalence of eosinophilia was 44%, with no significant difference between asthmatics and non-asthmatic patients (49% versus 43%). Eosinophilia was found in 8.4% of the control group. Asthma was more prevalent among patients with eosinophilia (22%) than without eosinophilia (6.4%).

Conclusions: Asthma is 3 times as prevalent in adults of Ethiopian origin, compared with the general population in our clinics, and markedly increased above the rate reported for newly immigrated Ethiopian Jews. We conclude that the move from the rural hills of Ethiopia to the more urban and industrialized setting of Israel has resulted in an increased prevalence of asthma in this population, but the specific cause is uncertain.

International Family Medicine
(Fam Med 1999;31(4):276-9.)