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ABSTRACTS
Special
Series: Longitudinal Residency Training
Longitudinal
Residency Training: A Survey of Family Practice Residency
Programs
Carin
E. Reust, MD
Background
and Objectives: Most family practice residency training
consists of 2-4-week block rotations in specific curricular
areas, supplemented by training in the family practice
center. An alternative model, longitudinal residency
training, emphasizes training in curricular areas over
a 3-year time period. This study determined the frequency
of longitudinal training in family practice residency
programs. Methods: We conducted a survey of 477 residency
program directors listed in the American Academy of
Family Physicians 2000 Directory of Family Practice
Residency Programs. Results: Sixty-eight percent (n=320)
of program directors responded to the survey. A total
of 3.6% of program directors described their program
as "mostly longitudinal," and 14.2% described
their program as "half block/half longitudinal."
An additional 15% of program directors indicated interest
in adopting or moving toward a longitudinal program
in the next 2 years. Responses suggest some inconsistencies
in program directors' understanding of what constitutes
a longitudinal curriculum. Conclusions: Longitudinal
residency training is reported in 18% of family practice
residency programs. Further work is needed to develop
a definition of longitudinal residency training.
(Fam
Med 2001;33(10):740-5.)
Longitudinal Versus Traditional Residencies: A Study
of Continuity of Care
Dan
Merenstein, MD; Frank D'Amico, PhD; Brian Devine, MD;
Kiame J. Mahaniah, MD; Mia Solomon, PhD; Carin E. Reust,
MD; DJ Rosenbaum, MD
Background
and Objectives: Continuity of care is one of the presumed
advantages of longitudinal residencies. However, it
is not clear how well such residencies provide continuity
of care, and, further, there is no recognized acceptable
rate of good continuity. We compared traditional and
longitudinal residencies to determine the extent to
which the residents provided their patients with continuity
of care. Methods: We conducted a systematic chart review
at three longitudinal and three matched traditional
block-rotation programs. In total, 628 charts were reviewed,
and 6,256 visits were evaluated. Continuity with a primary
resident was evaluated over a 2-year period, with continuity
defined as the percentage of visits for which the patient
saw the same resident. Results: There was no significant
difference in overall rates of continuity between longitudinal
and traditional programs (59.6% versus 57.8%). One longitudinal
program, however, had a 74.8% rate of continuity, which
was significantly higher than the rates in the other
five programs. Conclusions: There was no significant
difference found in continuity of care provided by residents
at longitudinal programs, compared with those at traditional
programs. Our results do not support the hypothesis
that longitudinal residency programs achieve superior
rates of continuity of care. Further comparison studies
of longitudinal and traditional programs would be useful.
(Fam
Med 2001;33(10):746-50.)
Improving Continuity by Increasing Clinic Frequency
in a Residency Setting
Jon
O. Neher, MD; Gary Kelsberg, MD; Drew Oliveira, MD
Background
and Objectives: Continuity of care is required in family
practice training programs. However, continuity for
some patients may not be adequately served in the traditional
training model that has residents in the family practice
center (FPC) for 1 to 3 half-day clinics per week. This
study sought to determine if increasing clinic frequency
in a family practice residency has an effect on continuity
of care. Methods: On January 1, 1999, the residency
program changed from a traditional clinic scheduling
model to one where all residents saw patients in the
FPC 4 to 5 days a week. By using shorter clinic sessions,
total resident time in the FPC was nearly unchanged
(decreasing 5% overall). We reviewed 1,709 randomly
selected billing records for residents' patients who
frequently utilized medical care (three or more visits
within 6 months) and assessed continuity for 1 year
before and after this intervention, using both the modified,
modified continuity index (MMCI) and the percentage
of visits to the primary care provider (PCP). Results:
Overall, the MMCI for patients who frequently saw residents
increased from .59 to .64. The average frequency with
which these patients saw their PCPs improved for the
first-year class (from 51% of visits before implementation
to 72% after) and the third-year class (from 66% of
visits to 72%). Conclusions: Scheduling daily resident
clinics in the FPC increased continuity among patients
who frequently saw residents beyond that achieved using
traditional scheduling, without increasing total resident
time in the FPC.
(Fam
Med 2001;33(10):751-5.)
Are Some Subjects Better Taught in Block Rotation?
A Geriatric Experience
Kenneth
K. Steinweg, MD; Doyle M. Cummings, PharmD; Suzanne
K. Kelly
Background
and Objectives: This study characterizes the progress
in and effectiveness of learning geriatric medicine
during longitudinal and block phases of a family practice
residency program. Methods: A structured second-year
geriatric block rotation was added to a residency longitudinal
curriculum. To assess learning, a Geriatric Assessment
Instrument (GAI) consisting of 50 multiple choice questions
was administered to three classes of family practice
residents (n=33) five times during training: entry into
the program, beginning of the second year, pre- and
post-geriatric block rotation, and at graduation. Improvement
between individual resident first- and third-year in-training
exam scores in geriatrics of the intervention classes
were compared with the four classes that preceded the
introduction of the block rotation (n=38). Results:
Scores on the GAI improved significantly before and
after the rotation but not during any other interval
of training during the residency. In-training exam scores
improved significantly for the classes taught with the
block rotation over those without it. Conclusions: Most
of the geriatric learning occurred during the 1-month
geriatric block rotation during the residency. In-training
geriatric exam scores improved significantly with a
geriatric block rotation. The use of structured repetitive
learning experiences during the rotation to emphasize
the common clinical issues and the skewed exposure to
geriatric patients in the random nature of residency
clinic and inpatient encounters account for this result.
(Fam
Med 2001;33(10):756-61.)
Longitudinal
Residency Training in Family Medicine: Not Ready for
Prime Time
Barry
D. Weiss, MD
Many
family medicine educators have called for changing the
family practice residency curriculum from a series of
block rotations to a longitudinal curriculum. A longitudinal
curriculum is one in which residents are based in the
family practice center every day or nearly every day
of all 3 years of their residency training. Residents
learn most of the clinical content of family medicine
through experiences with patients from their continuity
clinics, under supervision of family medicine faculty,
rather than through specialty-specific block rotations
supervised by specialists. An important purported benefit
of longitudinal training is improved continuity of care
between residents and their patients. Unfortunately,
definitions of longitudinal training vary widely, and
at least one study shows that supposedly longitudinal
curricula do not result in better continuity of care.
Further, there is some evidence that acquisition of
knowledge by residents may be better with intensive
block rotations than with longitudinal training. Thus,
the supposed benefits of longitudinal residency training
remain unproven.
(Fam
Med 2001;33(10):762-5.)
Residency
Education
Rural-Urban
and Gender Differences in Procedures Performed by Family
Practice Residency Graduates
R.
Gordon Chaytors, MD; Olga Szafran, MHSA; Rodney A. Crutcher,
MD, MmedEd
Objective:
We compared the types of procedures performed and obstetrical
care provided by family practice residency graduates,
by practice location and physician gender. Methods:
We conducted a cross-sectional questionnaire survey
of 702 graduates who completed family practice residency
programs in Alberta, Canada, from 1985 to 1995, inclusive.
Graduates were asked to indicate which of 28 procedures
and 7 obstetrical care practices they performed. The
data were analyzed by gender and current practice location.
Results: A total of 442 (63%) of the graduates responded
to the survey. The top five procedures performed by
family practice graduates were minor office surgery,
foreign body removal (eye), joint aspiration, joint
injection, and anterior nasal packing. There was a declining
trend in the number of procedures performed by family
practice graduates from rural, to regional, to metropolitan
areas. Relatively more males performed procedures; however,
more females did IUD insertion and obstetrical care
practice. Except for a few exceptions, a similar proportion
of male and female graduates in rural practice performed
procedures. Conclusions: The procedural and obstetrical
care pattern of practice differs between family practice
graduates in rural and urban areas, as well as between
male and female graduates. Family practice residency
programs should consider additional training in procedural
skills for those planning to practice in rural areas,
as well as encourage females to become skilled at performing
procedures relevant to family practice.
(Fam
Med 2001;33(10):766-71.)
Clinical
Research & Methods
Development of the HIV/AIDS Q-Sort Instrument to
Measure Physician Attitudes
Raghavendra
S. Prasad, MD
Background:
Providers' attitudes about HIV/AIDS are an important
dimension in the delivery of quality care to persons
with HIV/AIDS. It is believed that education can alter
attitudes, but there is a need for a user-friendly instrument
to measure the effect that HIV/AIDS educational programs
have on attitudes. Methods: A pool of HIV/AIDS attitude
descriptors was collected through literature review
and from individuals working in the HIV/AIDS field.
Out of this pool of 90 descriptors, 48 descriptors with
the highest face validity were selected through expert
consensus ranking to create a preliminary survey instrument.
Twenty-six physicians completed a pilot Q-Sort instrument
with 48 descriptors. A variance analysis was conducted,
and the top 28 descriptors with the most variability
were selected for the final Q-Sort instrument, which
was then completed by 191 physicians. A factor analysis
was conducted to identify a small number of factors
that explained the 28 descriptors. A subsample of 22
physicians repeated the test to establish test-retest
reliability. Results: Factor analysis revealed three
factors: (1) emotionality, (2) ability, and (3) reluctance.
The Q-Sort instrument demonstrated good test-retest
reliability, with reliability for the three factors
of .82, .80, and .88, respectively. Conclusions: This
Q-sort instrument is a reliable method for measuring
physician attitudes toward HIV/AIDS patients. Further
studies can test its use for evaluating the effect of
educational programs on changing provider attitudes.
(Fam
Med 2001;33(10):772-8.)
Innovations
in Family Medicine Education
A
Senior Elective: Promoting Health in Underserved Communities
Marie
Wolff, PhD; Staci Young; Cheryl Maurana, PhD
Objectives:
A fourth-year service-learning elective was developed
to teach medical students about the social, economic,
and cultural factors that affect health and health-seeking
behavior. Description: The elective provides students
with didactic material and educational experiences in
public housing sites in the community. Students work
closely with community members to implement a community
health care intervention. Evaluation: Students respond
to 10 reflection questions that assess their understanding
of the important community factors that affect health.
Conclusions: Reflection responses demonstrate that the
course has challenged assumptions, dispelled stereotypes,
and enhanced awareness of the role of social factors
in maintaining health.
(Fam
Med 2001;33(10):732-3.)
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