Background and Objectives: Management of the dying patient often elicits anxiety in physicians. This study identified the association of physicians’ personal fear of death, tolerance of uncertainty, and attachment style with physician attitudes toward dying patients.

Methods: Four psychological scales were distributed to family practice residents located in Texas, Missouri, and Maine. The scales were “Death Anxiety,” “Death Attitudes,” “Physicians’ Reactions to Uncertainty,” and “Experiences in Close Relationships.” The scores from the measures and demographic data were used to determine which factors were associated with physician attitudes toward caring for terminally ill patients.

Results: Completed surveys were received from 157 residents. Younger residents (<30 years) reported more stress from uncertainty and were more uncomfortable with the care of dying patients. Residents who reported higher death anxiety were also more uncomfortable with caring for dying patients. In a multivariate analysis, uncertainty, death anxiety, and age predicted 26% of the total outcome variance of the death attitudes score.

Conclusions: Physician tolerance of uncertainty plays a significant role in physician attitudes toward the dying patient. Our findings suggest that decreasing physicians’ stress from uncertainty by educating them in the management of the dying patient may improve their attitude toward death and may better prepare them to provide end-of-life care.

Residency Education
(Fam Med 1999;31(10):691-6.)

Residency Orientation: What We Present and Its Effect on Our Residents
Michael Grover, DO; Sandra Puczynski, PhD

Background and Objectives: This study describes the content of family practice residency orientation programs, presents data about resident satisfaction with orientation, and determines if residents feel prepared for residency duties.

Methods: We surveyed program directors and first-year residents at 100 family practice residency programs. We used questionnaires to collect data about orientation activities; program demographics; and resident characteristics, satisfaction, and preparation.

Results: Sixty-nine percent of directors and 68% of their residents responded. The activity most frequently presented was a social event with faculty, while the least frequently presented was an assessment of cognitive knowledge. Even though residents desire orientation to clinical programs, and directors wish to promote group cohesion, the greatest number of orientation activities were presented to introduce hospital services and administration. Eighty-seven percent of residents were at least “somewhat satisfied,” and 83% felt at least “somewhat prepared” for clinical duties after completing orientations. Residents from military programs were more likely not to be satisfied with their orientations. Extreme satisfaction was associated with residents in community-based programs. Being totally prepared was associated with having had prior graduate medical education.

Conclusions: While residents had previously reported having clinical needs from an orientation, the most frequently reported activities were nonclinical. Most residents reported having been satisfied with their orientations and having felt prepared for their new duties. Directors should consider increasing the clinical content of their orientations, including an assessment of residents’ knowledge and clinical skills.

Residency Education
(Fam Med 1999;31(10):697-702.)

Training Medical Students in Evidence-based Medicine:
A Community Campus Approach
William C. Wadland, MD, MS; Henry C. Barry, MD, MS; Lynda Farquhar, PhD; Claudia Holzman, DVM, MPH, PhD; Anne White, MDiv, MPH, MD

Background and Objectives: Clinicians need skills in critical appraisal of medical literature to improve quality of care. This report on evidence-based medicine (EBM) curricula describes 1) the role of family medicine educators, 2) timing, 3) value of a standard format across multiple communities, and 4) outcomes in attitudes and skills.

Methods: In 1992, a nine-session curriculum delivered across six community campuses was introduced during the third year of medical school in the College of Human Medicine at Michigan State University. Evaluation compared 1) responses on the Association of American Medical Colleges graduation questionnaires from classes who received the curriculum with the 1994 class who did not (424 students), 2) responses to questions on group process performance, and 3) focused surveys of two classes.

Results: Trained classes reported higher levels of confidence in critical appraisal and research skills than the 1994 class and other schools. Respondents reported the small-group process as effective, greater appreciation of the training after 1 year of residency than at graduation, and no change in research activity.

Conclusions: Family medicine educators can lead a new curriculum in EBM and maintain consistent standards across multiple communities. Many questions remain concerning the ideal curricular design to help clinicians apply the best research to patient care.

Medical Student Education
(Fam Med 1999;31(10):703-8.)

Family Medicine Research Funding
Doug Campos-Outcalt, MD, MPA; Janet Senf, PhD

Background and Objectives: While the specialty of family practice has achieved parity with other specialties in many areas, it lags behind in research productivity. This article explores current and historical funding levels of family medicine research from the National Institutes of Health (NIH) and the Agency for Health Care Policy and Research (AHCPR).

Methods: Funding amounts from NIH to medical schools and family medicine departments were obtained for the years 1984–1997. Funding amounts from AHCPR awarded to family physicians and the total AHCPR research budget were obtained for 1991–1995.

Results: In 1997, family medicine departments were awarded $18.6 million from the NIH, .4% of the NIH research awards. The amount from NIH has increased progressively since 1984, but the proportion of the total NIH budget has increased only marginally (from .3% to .4%). In 1995, family medicine researchers obtained $6.7 million from AHCPR, 4.0% of the AHCPR research budget. Since 1991, this amount has increased slightly, but as a proportion of the AHCPR budget, it has declined (from 4.4% to 4.0%).

Discussion: The NIH is an increasingly important source of support for family medicine researchers, while AHCPR support has plateaued. Even though NIH support of family physician researchers is increasing, the proportion of NIH funding awarded to family medicine departments remains below the proportion of US medical school faculty who are family physicians. One possible cause of this discrepancy is a lack of a locus of primary care and family medicine research funding.

Faculty Development
(Fam Med 1999;31(9):635-40.)

Randomized Clinical Trial of a Diagnostic Instrument for Pain Complaints
Stephen E. Radecki, PhD; Stephen A. Brunton, MD

Background and Objectives: This study evaluated use of the patient-administered Personal Pain Tracker in ambulatory primary care practice and tested the hypothesis that use of the instrument is associated with greater patient satisfaction with physician-patient communication regarding pain.

Methods: This randomized clinical trial was conducted in the offices of 12 family physicians practicing in Los Angeles and Orange Counties in Southern California. Study subjects consisted of 79 patients who presented with pain complaints during the study’s enrollment period and who conformed to the inclusion and exclusion criteria. Patients randomized to the experimental arm of the study received and completed the Pain Tracker, and both these patients and control group patients participated in a telephone interview with an investigator 1 week subsequent to their visit.

Results: Regardless of the specific nature or cause of their pain, patients randomized to the Pain Tracker group were substantially more likely to report that their physicians felt that their pain was genuine and were concerned about it, asked enough questions about the pain and listened carefully, gave them a chance to provide a complete explanation, and performed a thorough examination. Patients in the Pain Tracker group also reported a higher level of overall satisfaction with their visit.

Conclusions: Use of the Pain Tracker instrument improves patients’ perceptions of the quality of physician-patient communication regarding pain complaints and results in greater overall satisfaction with medical visits.

Clinical Research and Methods
(Fam Med 1999;31(10):713-21.)

The Problem Resident: Learning From Our Mistakes
Anonymous

Every program has its “problem” resident(s). Residents who are academically deficient or who have aggressive styles are well-known to most programs. But, less frequent (or simply less discussed) is the true outlier resident: the resident with a drug or alcohol addiction, the severe personality disorder, the one who is physically and/or verbally aggressive, or one with a criminal history. Our program had the dubious distinction of encountering all of these problems in a single resident. Although we accepted him into the program following a standard reference check, little did we know how little we actually knew about him or his background. This paper is a description of our experience and effort in coping with this stressful situation and is a call for significant change in the whole recruiting process to help reduce or purge graduate medical education of severely dysfunctional trainees.

Commentaries and Essays
(Fam Med 1999;31(10):729-31.)