| Special
Article
Malpractice Liability for Informal Consultations
Robert S. Olick, JD, PhD; George R. Bergus , MD, MAEd
Background: Informal (“curbside”)
consults are widely used by primary
care physicians. These interactions
occur in person, by telephone, or even by e-mail. Exposure to malpractice liability
is a frequent
concern of subspecialty physicians and influences their willingness to engage
in this activity. To assess
this risk, we reviewed reported judicial opinions involving informal consultation
by physicians. Methods:
A search of the existing medical literature, and of the Westlaw® national
database was undertaken to
identify reported judicial opinions involving informal physician consults that
address whether informal
consultations create a legal relationship between consulting specialist physicians
and patients that gives
rise to a legal duty of care owed by the consulting specialist to the patient.
Conclusions: Courts have
consistently ruled that no physician-patient relationship exists between a consultant
and the patient who
is the focus of the informal consultation. In the absence of such a relationship,
the courts have found no
grounds for a claim of malpractice. Malpractice risks associated with informal
consultation appear to be
minimal, regardless of the method of communication. While “informal consultation” is
not a term used by
the courts, the courts have applied a consistent set of criteria that help define
the legal parameters of this
activity.
(Fam Med 2003;35(7):476-81.)
Residency
Education
Muddling
Through a Merger: A Qualitative Study
of Two Combined Family Practice Residencies
Mindy Smith, MD, MS; Peter Graham, MD; Jodi Summers Holtrop, PhD, CHES;
Clayton Thomason, JD, MDiv; Barbara Joyce, PhD
Background and Objectives: Mergers of residency training programs have become
more common, but little has been published about their educational impact.
Following our own merger, we sought to understand this process and its aftermath
by conducting focus groups. Methods: Three 1-hour focus groups were conducted—one
with third-year residents, one with first- and second-year residents, and one
with core faculty members. The interview script was based on a five-factor
transitional model where each factor represented a potential fracture point
that could result in organizational conflict. The five factors were curriculum,
corporate culture, day-to-day operations, teaching environment, and financial
resources. Focus group audiotapes were transcribed, and the investigators independently
identified themes using an immersion and crystallization approach. Feedback
from participants was obtained. Results: Themes identified included unmet potential
of the combined curriculum, a blending of two disparate cultures resulting
in feelings of loss and displacement for some, and a sense of rapid policy
change and lack of resident and faculty accountability. Faculty recommendations
for other programs involved in mergers include creating frequent facilitated
retreats, acknowledging loss, and establishing new rituals for the combined
program. Conclusions: The transition through a merger of two residency programs
is difficult and has direct educational and emotional impact. Such difficulties
can, in part, be predicted, and improved communication and planning may facilitate
this process.
(Fam Med 2003;35(7):482-8.)
Effectiveness
of a Clinical Interviewing Training
Program for Family Practice Residents:
A Randomized Controlled Trial
Roger Ruiz Moral, MD, PhD; Juan Jose Rodriguez Salvador, MD;
Luis Perula de Torres , MD, PhD; Jose Antonio Prados Castillejo, MD, PhD,
on behalf of the COMCORD Research Group
Background and Objectives: This study evaluated the effectiveness of
a clinical interviewing training program for third-year family practice
trainees and determined which other factors influence residents’ training
in clinical communication. Methods: This was a randomized, multicenter,
educational trial involving 193 third-year family practice residents
from eight centers in Spain. Centers were randomly assigned to two
groups, one of which would undertake a communication skills training
program and one of which would not. The program was resident centered,
based on residents’ practice experience, and provided structured
feedback. The main outcome measures were residents’ consultation
behavior with six standardized patient encounters (three before and
three after the training) as measured with the GATHA-RES rating scale
by an observer blinded to group assignment of the residents. Results:
The intervention group trainees displayed marginally better communication
skills at the start of the study than those in the control group. At
the end of the study, trainees who had received the training program
did not show better communication skills than those who had not received
the training program. Factors related to the training center environment,
having a teacher trained in clinical interviewing, younger age, and
a longer interview duration correlated with better communication skills.
Conclusions: The trial program did not appear to improve the global
communication skills of trainees. This study highlights the importance
of the trainee’s teachers, the residency program environment,
and earlier exposure to training in planning future programs to improve
residents’ communication skills.
(Fam Med 2003;35(7):489-95.)
Development
and Content Validation of Family Practice Residency Recruitment Questionnaires
Lorraine Silver Wallace, PhD; Gregory H. Blake, MD, MPH;
Jon S. Parham, DO, MPH; Ruth E. Baldridge, MD
Background and Objectives: The residency recruitment process involves a substantial
time and financial commitment on the part of medical students and residency programs.
This paper describes the development and content validation process of two written
questionnaires designed to assess the application and interview process at our
family practice residency program. Methods: Two written questionnaires were developed
after completion of a literature review and from areas deemed important by our
academic faculty. Drafts of each questionnaire were sent to nine jurors to assess
content validity. Content reviewers provided both a qualitative and a quantitative
assessment of each questionnaire. Results: The inclusion of both open- and closed-ended
questions/items was deemed necessary and appropriate by the panel of content
jurors. Assessing faculty, residents, curriculum, program’s reputation,
geographic location, and spouse/family influence were considered the most important
factors to include on the questionnaires when assessing a family practice residency
program. Conclusions: With increasing pressure to fill positions across many
family practice residency programs, it is important for faculty involved in the
recruitment process to recognize that both factors within and out of their control
contribute to the selection process.
(Fam Med 2003;35(7):496-8.)
Medical
Student Education
A
Comparison of Family Medicine and Internal Medicine Experiences in a Combined Clerkship
Terry J. Bahn, EdD; Holly R. Cronau, MD; David P. Way, MEd
Background: Learning experiences during the medical school clinical rotation
are largely shaped by patient contacts in a variety of clinical settings.
For this reason, it is important to learn as much as possible about whether
learning goals are being met. The patient encounter log has been used as
a program evaluation tool to track students’ clinical experiences.
Methods: In the present study, we used a scannable pencil and paper form
to compare clinical and demographic data from two primary care experiences
in a multidisciplinary clerkship. Students manually recorded the encounter
date, patient age and gender, the students’ level of involvement with
the patient, and involvement with procedures. Up to four diagnoses relevant
to the encounter were also recorded. To document the clinical content of
the encounters, International Classification of Diseases, 9th Revision, Clinical
Modification (ICD-9- CM) codes were used. Results: Differences in patient
encounters were found in five of the most frequently logged ICD-9-CM categories
and also the presence of multiple diagnostic categories. Fewer family medicine
encounters could be categorized as observational than general internal medicine
encounters, and students on the family medicine month conducted physical
examinations more frequently. Lower patient age was recorded for family medicine
patients seen. Patient gender was balanced and comparable for the two specialties.
The majority of the most frequently logged ICD-9-CM categories were strikingly
similar. The range of diagnoses logged was identical. Students also documented
similar opportunities for first contact with patients, doing patient histories,
and the lack of exposure to procedures. Conclusions: Ambulatory family medicine
and internal medicine experiences can be both reinforcing and complementary,
resulting in a more complete view of primary care. Common exposures in some
diagnoses, ie, hypertension, can illuminate subtle differences in how family
physicians manage patients in contrast to general internists. Students benefit
from “hearing it again” but also from seeing that different approaches
can lead to beneficial effects for patients. Other diagnoses that students
experience in family practice offices that differ from their internal medicine
rotation and vice versa ensure that students experience both the breadth
and depth of primary care.
(Fam Med 2003;35(7):499-503.)
Declining
Interest in Family Medicine:
Perspectives of Department Heads and Faculty
Randa M. Kutob, MD; Janet H. Senf, PhD; Doug Campos-Outcalt, MD, MPA
Background and Objectives: In 2003, US seniors filled 42% of family
practice residency positions, the lowest percentage in the specialty’s
recent history. We hypothesized that institutional support, contact with
family medicine faculty, and faculty satisfaction would be positively
related to choice of family practice and that faculty satisfaction would
be negatively affected by increasing pressure for clinical productivity.
Methods: We surveyed department heads and faculty at 24 US allopathic
medical schools, selected by their rate of family medicine graduates
from 1997 to 1999 and the size of the school. Twelve of these schools
had an increase in rates of graduates selecting family practice, and
12 showed decreases. Results: Department heads and faculty from schools
with an increase in student entry into family practice residencies were
significantly more likely to report financial and philosophical support
from their state legislature or medical school administration. Faculty
ranked patient care as most valued at their institutions, followed by
teaching, research, and service. A common theme emerging from both the
faculty and department head surveys was an inverse relationship between
research activity and graduates choosing family practice. Conclusions:
This study demonstrates the importance of upper-level institutional support
on family practice specialty choice. It also highlights a need for further
examination of the specialty’s relationship to research.
(Fam Med
2003;35(7):504-9.)
USMLE
Step 1 and 2 Scores Correlate With Family
Medicine Clinical and Examination Scores
Thomas Myles , MD; Rosa Galvez-Myles , MD
Background and Objectives: We sought to validate the family medicine
shelf examination by determining whether correlations exist between the US
Medical Licensing Examination (USMLE) family medicine final examination (FMF)
scores and the USMLE Step 1 or Step 2 scores. We also evaluated for correlations
between the family medicine clinical evaluation scores (CES), final clerkship
grades, and all of these examinations. Methods: The above scores (first attempts
only) of 258 third-year medical students at Texas Tech University at Amarillo
from July 1994 to June 2001 were obtained. Linear regression models were
made between scores. Low CES and examination or family medicine clerkship
failures were statistically compared. Results: The average scores were USMLE
Step 1: 203.7, USMLE Step 2: 203.8, FMF: 83.3, and CES: 90.1. Positive linear
correlations were seen between the Step 1 scores and both the FMF scores
and CES. Positive linear correlations between the Step 2 scores and both
the FMF scores and the CES were seen. Students failing the USMLE Step 1 were
more likely to fail the FMF as well as the family medicine clerkship. Students
with a CES less than the 10th percentile were more likely to fail the FMF
as well as the family medicine clerkship. Conclusions: USMLE Step 1 and Step
2 scores correlate linearly with both the FMF and CES of the third-year family
medicine clerkship. Students failing their USMLE Step 1 examination or having
a low CES are at risk for failure of the FMF as well as the family medicine
clerkship.
(Fam Med 2003;35(7):510-3.)
Practice
Management
Improving
Efficiency in a Residency Training Clinic: Results From Addressing a Root Cause of Inefficiency
George C. Xakellis , Jr, MD, MBA
Background: Since the early 1980s, primary care teaching clinics
have repeatedly been reported to be inefficient. This paper describes the
results of a 5-year effort to improve the efficiency of our residency teaching
clinic. Methods: This 5-year longitudinal tracking study of a clinic monitored
monthly patient volume, number of providers scheduled per half day, and patient
satisfaction with waiting times while interventions occurred to improve clinic
efficiency. Results: Prior to rigorously tracking the number of providers
in clinic, monthly clinic patient volume increased temporarily (1998–1999)
but fell back to baseline the following year. Variation in the number of
providers in clinic explained nearly half the variability in the number of
patients seen. After beginning a process of tracking and proactively optimizing
the number of providers in clinic per half day, patient volumes increased
significantly and stabilized at the higher levels. Patient satisfaction with
waiting time improved slightly. Conclusions: Tracking and optimizing a single
operational variable can improve clinic performance significantly. Reducing
the variation in the number of providers scheduled to see patients toward
an optimum number based on the number of available exam rooms resulted in
sustainable increases in the number of patients seen without any negative
impact on the patient satisfaction with waiting times.
(Fam Med 2003;35(7):514-8.)
Innovations in Family
Medicine Education
Integrating
Medical Abortion Into a Residency Practice
Linda Prine, MD; Ruth Lesnewski, MD; Rachel Bregman, MD
While changing residency services and curricula is difficult under
the best of circumstances, adding
something as controversial as medical abortion can provoke seemingly insurmountable
resistance.
This paper describes an innovative approach to adding medical abortion services.
We first surveyed
staff, faculty, residents, and colleagues to examine their reservations. These
concerns were addressed
in a structured manner, using a range of educational forums. While residents’ participation
in the service
was voluntary, all patients were assured access to medical abortion.
(Fam Med 2003;35(7):469-71.)
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