Background and Objectives: This study uses a cost construction approach to evaluate the cost of training family practice residents in a university-based residency program. The approach calculates the cost of the educational program from a global institutional perspective, including all monetary and nonmonetary costs, independently of how they are financed.

Methods: Cost construction analysis is used to compute the instructional cost, which includes the cost of faculty and resident time directly related to teaching and the support of the teaching program. The value of the clinical care and supervision provided by the family practice residents is assessed as a replacement cost. Sensitivity analysis examines a range of assumptions concerning residents’ productivity, replacement costs, and the cost allocation of activities that jointly produce clinical care and education.

Results: For a junior resident, the instructional cost is $94,835 per year, and the replacement cost is $65,052 per year. The value of the teaching and clinical services provided by senior residents, $124,247 per year, exceeds the cost of the resources used to educate them, $98,364 per year.

Conclusions: The cost construction model can be used as a tool to allocate resources, negotiate for funding, and estimate variations in cost due to changes in curriculum and in the health care environment.

Residency Education
(Fam Med 1999;31(3):159-70.)

Student and Faculty Perceptions of Problem-based Learning on a Family Medicine Clerkship
Martha Cole McGrew, MD; Betty Skipper, PhD; Toby Palley, MD; Arthur Kaufman, MD

Right From the Start: The Family Practice Orientation Study
Michael Grover, DO; Sandra Puczynski, PhD

Background and Objectives: Orientation to a residency program introduces residents to the essential functions of their duties, clarifies expectations, and acclimates them to a new social group. This study identified the orientation goals of family practice residency directors and compared those goals to the perceived needs of first-year family practice residents.

Methods: We surveyed program directors and PGY-1 residents at 100 accredited family practice residency programs. Questionnaires obtained descriptive information about orientation programs and resident demographics and assessed directors’ goals and residents’ needs from orientations.

Results: The orientation goal ranked most highly by directors was development of group cohesion. The need ranked most highly by residents was introduction to call duties and inpatient problems. Ranked responses of each group were not well associated.

Conclusions: The orientation goals of program directors and the reported orientation needs of residents were poorly associated. Most directors chose nonclinical areas as their most important goals for orientation. In contrast, most residents valued clinically related information during orientation to residency.

Residency Education
(Fam Med 1999;31(3):177-81.)

Balint Seminar Leaders: What Do They Do?
Joel H. Merenstein, MD; Kata Chillag, PhD

Background and Objectives: Balint seminars are part of the education of family practice residents in an estimated 30% of programs. Balint leaders are family physicians, psychiatrists, psychologists, and social workers with apprenticeship-type training. Balint leaders or Balint groups have never been formally evaluated.

Methods: We used multiple qualitative methods, including field observations, interviews, and focus groups. Field observations involved 12 Balint groups in 3 family practice residency programs. For comparison, we used videotaped seminars of 2 groups from the most recent Balint International meeting. In-person or telephone interviews were conducted with Balint leaders in a number of sites. We conducted focus groups with resident participants at each of the local sites.

Results: Although differences were seen among groups influenced by the group leader and the makeup of the group, there were consistencies across all of the groups. Contrary to the usual description of Balint leadership, these residency groups functioned partially as support groups, attempted to relieve or dampen anxiety, had a hierarchical system with the leader as the teacher/controller, and served an educational and a developmental purpose.

Conclusions: Balint leaders and their groups in the program studied did not function as traditionally described by Balint. Further observations of more groups are needed to determine if this variation is unique to the programs studied or is a manifestation of the transfer of the Balint method from experienced practitioners to physicians in training. This information will be of benefit to the development of appropriate training for future Balint leaders and for the credentialing process now being developed by the American Balint Society.

Residency Education
(Fam Med 1999;31(3):182-6.)

Physician Practice Style Patterns With Established Patients: Determinants and Differences Between Family Practice and General Internal Medicine Residents
Klea D. Bertakis, MD, MPH; John A. Robbins, MD, MHS; Edward J. Callahan, PhD; L. Jay Helms, PhD; Rahman Azari, PhD

Background and Objectives: This paper examines the practice style patterns of family practice and internal medicine residents for established patient visits.

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 by resident physicians. Initial and return visits were videotaped, and physician practice styles were analyzed using the Davis Observation Code (DOC).

Results: Resident physicians’ practice styles with established patients during return visits were associated with various factors, depending on the DOC cluster of behaviors studied. These factors include patient gender, age, income, physical and mental health status, level of pain, number of return visits, and physician practice style displayed during the initial encounter. Family practice return visits had a greater emphasis on preventive services and counseling, compared with internal medicine return visits. Internists spent more visit time using technically oriented behaviors.

Conclusions: Patient variables, as well as baseline physician behavior, have an important influence on physician practice styles during return patient visits. There are measurable differences in the established practice styles between family practice and internal medicine resident physicians, which may reflect differences in professional training programs.

Residency Education
(Fam Med 1999;31(3):187-94.)

Medical Students’ Attitudes Toward Abortion and Other Reproductive Health Service
Roger A. Rosenblatt, MD, MPH; Kirsten B. Robinson; Eric H. Larson, PhD; Sharon A. Dobie, MCP, MD

Background: The continued availability of legal abortions in the United States depends on the willingness of future physicians to provide this procedure. This paper explores the attitudes toward abortion issues of first- and second-year medical students at a large regional primary care-oriented medical school.

Methods: We anonymously surveyed 286 first- and second-year medical students at the University of Washington.

Results: The response rate to the written survey was 76.6%. Women were slightly overrepresented among the respondents. The majority of students supported the broad provision of reproductive health services; 58.1% felt that first-trimester abortions should be available to patients under most circumstances. Of the 43.4% of students who anticipated a career in family practice, most expected to provide abortions in their future practices. Older students and women were more likely to support the provision of abortion services.

Conclusions: Despite continuing pressure on abortion providers, most first- and second-year medical students at a fairly typical state-supported medical school intend to incorporate this procedure into their future practices.

Student Education
(Fam Med 1999;31(3):195-9.)

Teaching Medical Students Cancer Risk Reduction Nutrition Counseling Using a Multimedia Program
Kathryn M. Kolasa, PhD, RD, LDN; Ann C. Jobe, MD, MSN; Mary Guy Miller, PhD, MS; Maria C. Clay, PhD

Background and Objectives: There are many barriers to medical students receiving education about the linkage between nutrition and cancer, including the lack of role models and teachers and insufficient curricular time. We tested the use of a multimedia program as a possible solution to teaching diet-risk assessment and counseling skills.

Methods: Images of Cancer Prevention, The Nutrition Link is a CD-ROM multimedia program that was developed and evaluated by 147 medical students. Pre-use and post-use surveys, computer log files, and recorded response sessions were used to determine the learner’s 1) ease in using the program, 2) attitudes about the treatment of the content, 3) knowledge gain, and 4) attitudes about the role of physicians in nutrition assessment and counseling for cancer risk reduction.

Results: Students improved their knowledge of dietary guidelines for cancer risk reduction and made positive changes in their attitudes toward the role of physicians in dietary counseling. However, most students reported that they would not use the program unless it was required that they do so.

Conclusions: The multimedia program was successful; it affected students’ knowledge and attitudes concerning nutrition as a modifiable risk factor for some cancers. In addition, the design and delivery of the multimedia product was positively reviewed by the students for ease of access, message design, individualized instruction, and flexibility. Despite these favorable ratings, it was not clear that students would use the program unless required to do so.

Student Education
(Fam Med 1999;31(3):200-4.)