February 2003, Vol. 35, No. 2

The Effects of the 1997 Balanced Budget Acton Family Practice Residency Training Programs
Ronald Schneeweiss, MBChB; Roger A. Rosenblatt, MD, MPH; Susan Dovey, PhD; L. Gary Hart, PhD; Frederick M. Chen, MD, MPH; Susan Casey, PhD; George E. Fryer Jr, PhD

Background and Objectives: This study assessed the impact of the Balanced Budget Act (BBA) of 1997 on family practice residency training programs in the United States. Methods: We surveyed 453 active family practice residency programs, asking about program closures and new program starts (including rural training tracks), changes in the number of residents and faculty, and curriculum changes. Programs were classified according to their urban or rural location, university or community hospital setting, and rural and/or urban underserved mission emphasis. Results: A total of 435 (96%) of the
programs responded. Overall, the impact of the BBA was relatively small. In 1998 and 1999, nationwide, there were 11 program closures, a net decrease of only 82 residents, and a net increase of 52 faculty across program settings and mission emphasis. The rate of family practice residency program closures increased from an average of 3.0 per year between 1988–1997 to 4.8 per year in the 4 years following passage of the BBA. Conclusions: The 1997 BBA did not have an immediate significant negative impact on family practice residency programs. However, there is a worrisome increase in the rate of family practice residency closures since 1997. A mechanism needs to be established to monitor all primary care program closures to give an early warning should this trend continue.

(Fam Med 2003;35(2):93-9.)

The Relationship of Residency Performance to Match Status and US Versus International Graduate Status
Joseph Blonski, MD; Scott Rahm, MD

Background and Objectives: This study compared the performance of family practice residents selected through the National Resident Matching Program (NRMP) with those selected outside the NRMP and that of US medical graduates (USMGs) versus international medical graduates (IMGs). Methods: Surveys were mailed to all 470 US family practice residencies asking Match status and USMG versus IMG status of graduates accepted into their programs from 1994–1996. Results: Of 3,222 residents, 2,815 (87.4%) were accepted through the Match, 159 (4.9%) before the Match, and 248 (7.7%) after the Match; 2,874 (89.2%) were USMGs, and 348 (10.8%) were IMGs. Residents accepted after the Match versus residents selected through the Match were more likely to leave their programs early (14.5% versus 4.8%), score in the lower 10% of their In-training Assessment Examination (ITE) (11.7% versus 2.2 %), and require remedial programs (12.9% versus 2.6%). A lower proportion of residents accepted after the Match scored in the top 10% on the ITE examination (5.6% versus 15.2%). IMGs were more likely than USMGs to leave the program before graduating (8.0% versus 5.2%), to score within the lower 10% on the ITE examination (7.8% versus 2.5%), and to require remedial programs (7.8% versus 3.2%). Conclusions: Although a large majority of the residents studied here performed well, somewhat less-favorable performance was seen among residents accepted after the Match and among those with international medical degrees.

(Fam Med 2003;35(2):100-4.)

Nutrition Education in Family Practice Residency Programs
Darwin Deen, MD, MS; Elizabeth Spencer, MS, RD, CDE; Kathryn Kolasa, PhD, RD

Background and Objectives: Nutrition is a required part of family practice residency training. Unfortunately, little is known about the quality or effectiveness of this nutrition training. This study evaluated the current status of nutrition training in family practice residency training programs. Methods: We surveyed 100 randomly selected US family practice residencies about their nutrition education curriculum. Surveys were sent by e-mail, mail, fax, or administered by phone to individuals identified as responsible for nutrition teaching. A response rate of 66% was obtained. Results: Programs varied greatly in their emphasis on nutrition. Identified barriers were similar across most programs. The presence of at least a part-time faculty member dedicated to nutrition was correlated with perceived effectiveness of nutrition education efforts. Conclusions: If family physicians are to be prepared to inform their patients regarding nutrition and to make appropriate referrals, improvements in the nutrition curriculum offered in many family practice residency programs will be required. Readers can evaluate their program’s nutrition education efforts and see how they compare to our sample. Specific recommendations for potential changes are included.

(Fam Med 2003;35(2):105-11.)

Aspirin and Ibuprofen: Potential Mediators of the Cardiovascular Risk Due to Smoking?
Arch G. Mainous III, PhD; William S. Pearson, MHA

Background and Objectives: Smokers have elevated C-reactive protein (CRP), an indicator of systemic inflammation and a marker for increased risk for cardiovascular disease (CVD). This study investigated among smokers the relationship between CRP and use of the anti-inflammatories aspirin and ibuprofen. Methods: Data from adults (>17 years) collected in the National Health and Nutrition Examination Survey (NHANES III) was analyzed (n=8,850). Regression models were used to determine the independent relationship between aspirin and ibuprofen use and elevated CRP, controlling for demographics, body mass index, history of CVD, and health status. Results: Frequency of use of aspirin and ibuprofen among “ever smokers,” a population that includes current smokers and quitters, was associated with a decreased likelihood of having elevated CRP. Ever smokers with low frequency of use of either aspirin or ibuprofen had a lower likelihood of having elevated CRP similar to that for “never smokers.” In adjusted relationships, aspirin use was not significantly related to elevated CRP, while low use of ibuprofen had decreased odds of having elevated CRP compared to no use. Conclusions: These preliminary findings from a nationally representative survey suggest that among patients refractory to smoking cessation interventions, use of ibuprofen may be useful to decrease CVD risk.

(Fam Med 2003;35(2):112-8.)

Patient Pain: Its Influence on Primary Care Physician-Patient Interaction
Klea D. Bertakis , MD, MPH; Rahman Azari, PhD; Edward J. Callahan, PhD

Background and Objectives: Heightened awareness of the importance of appropriate pain management in health care delivery has stimulated researchers to examine the impact of patient pain on medical encounters. In this study, we explored how patient pain might influence the physician-patient interaction during medical visits. Methods: New adult patients (n=509) were randomized to see primary care physicians in videotaped visits at a university medical center. Self-reported patient pain was measured before the visit using the Visual Analog Scale and the Medical Outcomes Study Short Form-36 (MOS SF-36) pain scale; patient sociodemographics were also measured. Physician practice style during the visit was analyzed with the Davis Observation Code (DOC). Results: Regression analyses revealed that patient pain during the medical visit was associated with the physician spending a greater portion of the visit on technical tasks and a smaller portion on preventive services and other activities designed to encourage the patients’ active participation in their own health care. Conclusions: Patient pain may influence the physician-patient interaction and its outcomes. Primary care physicians should be aware that there may be less focus on patients’ active involvement in their own care and less emphasis on providing disease prevention when treating patients who are experiencing pain.

(Fam Med 2003;35(2):119-23.)

Building Capacity for Research in Family Medicine: Is the Blueprint Faulty?
Peter Curtis , MD; Perry Dickinson, MD; John Steiner, MD, MPH; Bruce Lanphear, MD, MPH; Kieu Vu

Background and Objectives: This study compared the training programs and career paths of family medicine graduates in the National Research Service Award (NRSA) Program for Research in Primary Medical Care with general internal medicine and general pediatric peers. Methods: We mailed a survey to NRSA fellows graduating from 23 programs nationally between 1988–1997. Personal characteristics, fellowship experience, current professional activities, and academic productivity were compared among primary care disciplines. Results: Of 215 NRSA participants, 146 (68%) completed the survey. Of the 131 primary care respondents, 25% were family physicians. During the fellowship, family physician trainees spent significantly less time in hands-on research activity (32%±12%) than internists and pediatricians (39%±17%). Family physician graduates also had less post-fellowship mentoring and were less likely to hold clinician/researcher faculty positions in academic centers. Family physician faculty spent far more time on clinical work and less time on research. Only 12.5% of family physician fellowship graduates published one or more articles per year, compared with 36.5% of their peers, and 30% had published nothing since graduation. Conclusions : Family physician graduates of this research training program did not achieve academic success comparable to their peers. Family physicians need more protected time for conducting research in their faculty positions and more sustained mentorship.

(Fam Med 2003;35(2):124-30.)

Best Practices Research
James W. Mold, MD, MPH; Mark E. Gregory, MD

“Best practices research,” described in this paper, refers to a systematic process used to identify, describe, combine, and disseminate effective and efficient clinical and/or management strategies developed and refined by practicing clinicians. It involves five steps: development of a conceptual model or series of steps, definition of “best” based on values and standards, identification and evaluation of potentially effective methods for each component or step, combination of most-effective methods, and testing of combined methods. The chronological development of this process is described with case examples, and the methodological steps are discussed.

(Fam Med 2003;35(3):131-4.)

Minnesota’s Rural Health School: Interdisciplinary Community Education
Daniel G. Mareck, MD

The Minnesota Rural Health School was established in 1996 and is administered by the University of Minnesota School of Medicine, Duluth. The program provides rural interdisciplinary clinical experiences for health professions students in seven community sites. The core disciplines include medicine, physician assistant, pharmacy, nursing, dentistry, and social work. There have been more than 230 participants. Students benefit by learning to work in collaborative teams and by participating in rural health care delivery. The communities benefit from service-learning projects, from the introduction of telecommunication technologies, and from the increased potential for recruiting future rural practitioners.

(Fam Med 2003;35(2):86-8.)