April 2003, Vol. 35, No. 4

Use of On-line Evidence-based Resources at the Point of Care
Background and Objectives: The utility of on-line evidence-based summary databases for answering clinical questions at the point of care is not well understood. Our objectives were to determine if family physician faculty could answer their questions using on-line resources and the proportion of answers that influenced patient care. Methods: This was a prospective study in which clinical faculty in an urban residency training office recorded their clinical questions and their search results. Results: Faculty asked 92 questions. Therapy, prognosis, and epidemiology questions were the most common types of inquiries. Fifty-four percent of the questions were fully or partially answered by use of an on-line resource; obtaining an answer required 5–10 minutes of searching. Physicians reported that 62% of the obtained answers modified their opinion, influenced the care of the current patient 56% of the time, and would affect the care of future patients 70% of the time. Slow Internet connection and interruptions were the most frequent barriers reported. Discussion: Practicing physicians inexperienced in the use of on-line evidence-based resources answered a proportion of their clinical questions that was comparable to reports of more-experienced searchers; however, the time required to find answers limits the practical use of these databases during patient care time. On-line summary databases such as those used in this study show promise in providing answers that influence care during the patient’s visit. With faster Internet connection (or handheld devices) and improved navigability, such resources have the potential to optimize health care in the primary care setting.

(Fam Med 2003;35(4):251-6.)

Real-time Information-seeking Behavior of Residency Physicians
Background: Practicing physicians rarely apply evidence-based medicine (EBM). Unlike their more-experienced counterparts, current residents probably participated in EBM curricula during medical school. The current study was designed to determine the extent to which they or their faculty spend time searching for evidence-based answers. This information will help guide the content and format of EBM curricula in residency programs. Methods: The method used was direct observation of 13 faculty and 25 residents combined with self-report. Number of clinical questions, sources consulted, search times, and satisfaction with answers were collected for clinical encounters. The setting was the University of California San Francisco-Fresno Family Practice Residency Program. Results: Participants asked 274 clinical questions over 215 patient encounters (1.3 per encounter). Residents generated 1.5 per encounter and faculty generated .8. The group sought immediate answers to 66% of questions, found satisfactory answers to 87% of these, and later pursued answers to only 6% of remaining questions. Most searches (66%) took less than 2 minutes. Physicians most commonly used another person or a pocket reference. Conclusions: Residency physicians have clinical questions but rarely use evidence-based sources to answer them.

(Fam Med 2003;35(4):257-60.)

Documenting Procedures and Deliveries During Family Practice Residency: A Survey of Graduates' Experiences, Preferences, and Recommendations
Background and Objectives: The University of Washington Family Practice Residency Network (UW Network) is in the process of implementing a Palm Pilot-based procedure and delivery documentation system throughout 16 residency programs. Our study examined the experiences of past UW Network graduates in obtaining hospital privileges and in documenting procedures and deliveries. Methods: A survey was mailed to 201 1999 and 2000 UW Network graduates, asking them questions about their experiences obtaining hospital privileges after graduation and documenting procedures and deliveries during their training. Results: A total of 124 surveys (62% response rate) were analyzed. Ninety-four percent of the respondents had applied for hospital privileges, and 84% received all the privileges they requested. Forty-four percent indicated they had to provide some written documentation to get hospital privileges, but only 7% had to provide more than a numeric total of procedures or deliveries. Respondents predominantly used log cards and Palm Pilots for data collection. Palm Pilots were preferred over log cards, and the Palm Pilot systems received higher satisfaction ratings. Conclusions: For the majority of graduates, detailed delivery and procedure information was not necessary to obtain hospital privileges. Nevertheless, there are other reasons to document training experiences, and graduates strongly advise family practice residents to record their procedure and delivery experiences. Family practice residency programs should consider giving house staff handheld computers to record the procedures they perform.

(Fam Med 2003;35(4):264-8.)

The Current State of Esophagogastroduodenoscopy Training in Family Practice Residency Programs
Background and Objectives: Esophagogastroduodenoscopy (EGD) is a useful diagnostic procedure to evaluate patients with upper gastrointestinal complaints. Although family physicians have demonstrated that they can competently perform EGD, only a minority of family physicians perform EGD. This study determined the current state of EGD training in US family practice residency programs and how often graduating residents seek EGD privileges. Methods: We conducted a cross-sectional descriptive study surveying program directors from all Accreditation Council for Graduate Medical Education-approved family practice residency programs regarding EGD training in their program. Results: Of the 471 surveys mailed, 441 (94%) were returned. A total of 143 (32%) program directors reported that their program offered EGD training, but only 58 (13%) actually trained at least one resident. Residents performed a mean of 20 ± 2.4 EGDs per resident, and residents trained by family physicians performed more EGDs than residents trained by other specialties. In July 2000, .04% of graduating family practice residents sought credentials for EGD, and their training occurred in 32 (7%) residency programs. Conclusions: Only a minority of family practice residents seek credentialing after residency to perform EGD.

(Fam Med 2003;35(4):269-72.)

The Effect of Medical Students' International Experiences on Attitudes
Background: We evaluated the effect of international electives on the attitudes of preclinical and clinical- year medical students with respect to serving underserved multicultural populations. Methods: A self-assessment instrument was used to measure attitudes of 146 students before and after participating in international electives. The same attitudinal items were also analyzed at two time intervals for 18 students who completed international electives as preclinical students and 76 class cohorts who did not. Results: Analyses show that the effect of international experiences is different for preclinical students and clinical students. For both groups, however, these experiences can develop and support perceptions and values conducive to serving underserved multicultural populations. These include reported increases in cultural competence and important personal attributes like idealism and enthusiasm. In addition, these experiences can heighten clarity about career roles, including those involving underserved multicultural patients. Conclusions: This study provides support for the hypothesis that international electives develop attributes that could benefit underserved multicultural populations.

(Fam Med 2003;35(3):273-8.)

Family Naqrratives, Culture, and Patient-centered Medicine
Background and Objectives: As part of our family medicine clerkship seminar on the patient-physician relationship, third-year students write about an illness episode within their own families. Methods: Using a grounded research approach, we examined 260 student narratives to extract the most significant meanings. Results: Significant themes that emerged include the role of family members in illness episodes, specific influences resulting from the family’s ethnicity or religion, experiences with socially unacceptable illnesses, experiences with death, appreciation of the moral trajectory of illness, and situations that display the fallibility and limitations of medicine. Conclusions: Writing exercises can help students recognize the centrality of narrative and of cultural values in medicine so they are better able to understand their patients and provide more patient-centered medical care.

(Fam Med 2003;35(4):279-83.)

Clinical Research in Family Medicine: Quantity and Quality of Published Articles
Background and Objectives: Publication of clinical research in peer-reviewed journals is an important measure of scholarly productivity. This study determined the quantity and quality of original clinical research published by family physicians. Methods: We surveyed clinical research papers published in the year 2000 in four leading family medicine research journals and research originating in a family practice institution but published in 16 non-family medicine journals. All were selected on the basis of relevance to family physicians and “impact factor.” The relevance and validity of papers was assessed using previously established criteria. Results: The survey of family medicine journals revealed a total of 170 original research articles. Ninety eight were from academic family practice programs, and the remaining 72 were from other medical specialties or health care institutions. Most of the papers were cross-sectional surveys. There were seven qualitative studies, six randomized controlled trials, and no systematic reviews from family practice programs in these journals. Eight of the articles were from practice-based research networks. A total of 79 articles were considered relevant or highly relevant, and 22 of these were also considered valid (Patient-oriented Evidence That Matters or POEMs). The survey of 16 non-family medicine journals revealed 37 clinical research papers: 16 surveys, nine prospective cohort studies, seven randomized controlled trials, three systematic reviews/meta-analysis, one qualitative study, and one case-control study. There were nine “highly relevant” papers—seven could be classified as POEMs. Conclusions: Most clinical family medicine research uses less-rigorous study designs, such as the cross-sectional survey. The majority of papers do not meet established criteria for relevance and validity. There are no standards or comparable studies to compare these results to prior years or to other disciplines.

(Fam Med 2003;35(4):284-8.)