| Award-winning
Research Papers From the American Academy of Family Physicians 2002
Annual Scientific Assembly Are Children
of Military Parents More Physically Fit Than Children of Civilian Parents?
Mark B. Stephens
, MD, MS; Jeffrey J. Harrison, DO; Cindy Wilson, PhD;
Robert L. Ringler, MD; Chris Robinson, PhD
Background and Objectives:
It is not
known whether parental activity levels influence
children’s physical fitness. Members of the military are required to maintain
standards of physical fitness, whereas the civilian population is not. We conducted
this study to compare fitness levels of children in military and civilian families.
Methods: This was a prospective cohort study of third-grade students from two
public schools in San Diego County, Calif. Attendees of one school included children
of enlisted service personnel. Attendees of the other school included officers’ children.
Civilian students attended both schools. Students’ physical fitness was
tested with several standard instruments, including time on a 1-mile run. Independent
variables included whether students had civilian or military parents, television
viewing habits, and parental military status (enlisted personnel versus officer)
as a surrogate marker for socioeconomic status. Results: A total of 170 of 246
(70%) eligible students completed the study. Children of military parents had
lower scores on the mile run and lower scores on other measures of fitness than
did children of civilian parents. Socioeconomic status (ie, child of officer
versus enlisted personnel) was the strongest predictor of poor fitness, with
children of enlisted service members scoring lower on all measures of physical
fitness than officers’ children. More television viewing was associated
with lower levels of fitness. Conclusions: Children of military parents did not
have a higher fitness level than children of civilian parents. Lower socioeconomic
status and more television viewing are associated with lower levels of fitness. (Fam Med 2003;35(5):404-7.)
Thyroid
Function Testing in Outpatients: Are Both Sensitive Thyrotropin (sTSH)
and Free Thyroxine (FT4) Necessary?
Anthony J. Viera, MD
Background and Objectives: Despite improved thyroid function testing assays,
appropriate use of these commonly ordered tests to detect thyroid dysfunction
remains controversial. This study determined if a normal sensitive thyroid
stimulating hormone (sTSH) test alone is sufficient to rule out thyroid dysfunction
in outpatients. Methods: This was a retrospective analysis of initial sTSH
and free thyroxine index (FT4) tests ordered during a 26-month period. Test
results were classified as concordant if both the sTSH and FT4 indicated the
same findings (ie, euthyroid, hyperthyroid, or hypothyroid). The results were
classified as discordant if the sTSH and FT4 did not indicate the same findings.
Results: There were 1,392 paired sTSH and FT4 results. Of 1,340 results classified
as concordant (96.2%), 1,187 specimens were consistent with euthyroidism, 41
with hyperthyroidism, and 112 with hypothyroidism. Of the remaining 52 (3.8%)
discordant results, 47 met the definition of subclinical thyroid dysfunction.
Excluding these 47 results yielded a concordance rate of 99.6%. Of the 1,192
normal sTSH results, FT4 was low in two and high in three. If FT4 tests had
not been ordered on the 1,192 specimens with normal sTSH levels, the savings
over the study period would have been more than $3,360. Conclusions: If the
sTSH is normal, the likelihood of an abnormal FT4 is very small. sTSH alone
is adequate to screen outpatients for thyroid dysfunction. Limiting FT4 tests
to those with abnormal sTSH results will result in cost savings. (Fam Med 2003;35(6):408-10.)
Maximizing
Neonatal Early Onset Group B Streptococcal Disease Prevention With Universal
Culture Screening at 35 to 37 Weeks Gestation: A Comparison
of GBS Detection Rates Between LIM Broth and CNA Culture Media
Christopher Orsello, MD; Ronald Dommermuth, MD
Background and Objectives: Group B streptococcal (GBS) disease is the
most common cause of early onset neonatal sepsis. The Centers for Disease Control
(CDC) recommends performing recto-vaginal cultures on pregnant woman to detect
GBS, followed by treatment of women with positive cultures. Our facility adopted
selective culture screening in 1997 using a colistin-naladixic acid (CNA) plate
media instead of the more expensive LIM broth media. CNA plate cultures cost
one third that of LIM broth and allow for final results in 24 hours, versus
48–72 hours with LIM broth. We hypothesized that CNA media saves time,
money, and detects GBS as effectively as LIM broth. This study determined which
media is superior at detecting recto-vaginal GBS. Methods: This was a case-control
study involving 152 consecutive pregnant patients at 35–37 weeks from
August 1 to October 1, 2001, at Naval Hospital Bremerton, Wash. We obtained
two recto-vaginal swabs from each patient. One was cultured in LIM broth and
the other on CNA medium. We then compared differences in the rates of positive
cultures with LIM broth versus CNA medium using chi-square statistics and calculation
of odds ratios (OR). Results: LIM broth detected GBS in 35 of 145 (24.1%) women
versus 21 of 145 (14.5%) using CNA. CNA failed to detect GBS in 15 cases in
which LIM broth succeeded (OR=1.88; 95% CI=1.03–3.4). Conclusions: LIM
broth is superior at detecting maternal GBS colonization and is recommended
over CNA plate to maximize prevention of early onset neonatal GBS disease. (Fam Med 2003;35(6):411-3.)
Residency
Education
The
Effects of an Educational Intervention for “At-risk” Residents
to Improve Their Scores on the In-training Exam
Gurjeet S. Shokar, MD
Background and Objectives: The American Board of Family Practice (ABFP) In-training
Exam (ITE) is one of the tools used to evaluate both a resident’s progress
through residency and the program itself. Investigators have examined the ITE’s
validity and reliability and predictors of resident performance, but no published
studies have reported the effects of initiatives to improve residents’ performance
on the ITE. This study examines the impact of an educational intervention on
low-scoring residents’ ITE composite scores. Methods: Second-year residents
at a university-based program were divided into two groups. The intervention
group, who took the educational intervention, all had PGY-1 scores < 400
on their composite score. The control group was comprised of residents scoring > 400
on their composite score as PGY-1s. The educational intervention involved intensive
group and independent study. Results: In the first year of the study, there
was an increase in the average composite score of 75 points in the intervention
group compared to the control group. In the second year, there was an increase
of 72.5 points, but these differences were not significant. Conclusions: These
composite score changes are not significant, and although this educational
intervention may have improved confidence among low-scoring residents, it did
not clearly improve their scores on the ITE.
(Fam Med 2003;35(6):414-7.)
Resident Acquisition
of Knowledge During a Noontime Conference Series
Anne Picciano, MD; Robin Winter, MD, MMM; Douglas Ballan, MD;
Bruce Birnberg, MSW; Maryann Jacks , MD; Euton Laing, MD
Background and Objectives: Noontime conferences are widely used in
family practice residencies. This study determined the effectiveness
of noontime conferences for increasing residents’ knowledge.
Methods: Twenty residents were tested monthly over 6 months and then
cumulatively on the content of noontime conferences. Results: Monthly
test scores of attendees versus nonattendees were compared using a
two-sample, two-tail t test. Results revealed the mean score of attendees
for short-term knowledge to be 12.1 points higher than nonattendees.
There was no correlation, however, between conference attendance and
long-term knowledge retention. Conclusions: Our findings indicate a
lack of correlation between noontime conference attendance and long-term
cumulative test scores. The results question the value of noontime
conferences as a teaching method.
(Fam Med 2003;35(6):418-22.)
Does Time Use in
Outpatient Residency Training Reflect Community Practice?
Edward J. Callahan, PhD; Kurt C. Stange, MD, PhD; Klea D. Bertakis, MD, MPH;
Stephen J. Zyzanski, PhD; Rahman Azari, PhD; Susan A. Flocke, PhD
Background: The degree to which the ideals practiced during residency training
persist amidst the pressures of community practice is unknown. Therefore, this
paper compares time use during outpatient visits to family practice residents
and experienced family physicians. Methods: Visits of 244 new adult outpatients
to 33 second- and third-year residents in a university clinic in Northern California
were compared to 277 new adult outpatient visits to 92 community family physicians
in Northeast Ohio, using the Davis Observation Code (DOC). The DOC uses observation
to classify visit time into 20 different behavioral categories, reflecting different
physician styles of interaction with patients. Results: Controlling for patient
mix, residents had longer visits, a less technical focus, and spent a greater
percent of the visit on efforts to promote health behavior change, patient activation,
preventive services, discussion of substance abuse, and counseling. Conclusions:
Experienced family physicians provide more technical and less preventive and
psychosocially oriented care than residents. This may reflect differences in
patient mix, practice setting, physician experience, and the time and financial
pressures of community practice. These findings may be used to modify residency
training to better reflect actual community practice and to guide future studies
of the effects of experience and different practice environments on physician
style with patients.
(Fam Med 2003;35(6):423-7.)
Resident
Physicians Who Continue Balint Training: A Longitudinal Study 1982–1999
Alan H. Johnson, PhD; Clive D. Brock, MD; William J. Hueston, MD
Background and Objectives: Balint seminars began in London in 1950 on a voluntary
basis for general practitioners wishing to explore psychological problems in
their practice. By 1964, there was a 36% early dropout rate among the 223 physicians
who participated. This study sought to determine if those who leave Balint
training during their residency, versus those who continue, have different
psychological characteristics. Methods: A retrospective analysis of 206 Medical
University of South Carolina family practice residents from 1982 to 1999 was
completed. All residents participated in 6 months of required Balint training
and then could leave the Balint group or continue for the remaining 2 years.
We examined gender and personality attributes, comparing residents who completed
2 years of weekly Balint training and residents who left after 6 months. Personality
attributes were measured with the Myers-Briggs Inventory, the Work Environmental
Preference Schedule, the Internal-External Locus of Control, the Fundamental
Interpersonal Relationship Orientation Behavior test, and the Personal Orientation
Inventory. Results: A total of 132 residents completed 2 years of weekly Balint
training, and 74 discontinued training after 6 months. Two-year attendees were
significantly more intuitive on the Myers-Briggs Personality Inventory (MBTI).
There were no significant differences on other MBTI items, nor were there significant
differences in gender or in scores on the other psychological tests. Conclusions:
Based on the rate of discontinuation of Balint training in our sample, Balint
work does not appear to be suited to all physicians. With the exception of
one MBTI characteristic, no significant differences could be demonstrated between
those who did and did not continue participating. Further study is necessary
to define other attributes characterizing Balint group attendees and nonattendees.
(Fam Med 2003;35(6):428-33.)
Faculty
Development
Outcomes of a Comprehensive
Faculty Development Program for Local, Full-time Faculty
Jeffrey A. Morzinski, PhD, MSW; Deborah E. Simpson, PhD
Background and Objectives: Family medicine has a long history of
using faculty development programs (FDPs). Recent evaluation reports of those
programs highlight participant achievements in FDPs but underscore the need
for stronger evaluations of those programs. This study examined the outcomes
of a comprehensive, 2-year, within-institution FDP focused on participants’ productivity
and retention in academics. Methods: Subjects were 30 full-time FDP completers
(1993 through 1999). The curriculum included monthly seminars and mentor
involvement to promote competence in education, research, writing, administration,
professional academic skills, and technology. Projects were required in education,
research, and administration. Four evaluation levels were examined: reactions,
learning, behavior change, and results. Instruments included satisfaction
surveys, validated competence measures, CV review, and attendance and retention
records. Ten years of data from six training cohorts were analyzed. Results:
Reaction data showed 80% attendance and high program satisfaction. Learning
outcomes revealed positive pre- to post-program changes in each curriculum
area. Behavior changes included a pre- to postprogram tripling of institutional
leadership positions. Yearly group averages of peer-reviewed publications
increased from seven before the program to 26 after the FDP. Results showed
that 80% of participants were retained in academic careers through the 2-year
post-program time frame. Conclusions: Significant, positive outcomes were
found at all evaluation levels. This multi-level, longitudinal design may
contribute to future FDP evaluations.
(Fam Med 2003;35(6):434-9.)
International
Family Medicine
Primary Care Training
in Kosovo
Masahiro J. Morikawa, MD, MPH
Primary care training during and after conflicts is one of the most
challenging health care issues but is often neglected compared to emergency
medical care. Recently, family medicine has been increasingly used
as a model strategy to reconstruct primary care delivery systems in
communities torn by conflicts. The lessons learned through providing
primary pediatric care training in Kosovo, in two periods, both shortly
before the NATO air strike and after the war in Kosovo, are shared
in this paper. The training program was organized and provided in collaboration
with the Kosovar nongovernmental organization, Mother Teresa Society,
and Kinderberg International in support of United Nations High Commissioner
for Refugees as a pilot program. This paper provides a narrative description
of training experiences that focused on practical bedside training
and morale support throughout these two periods. Based on our evaluation,
providing morale support at the field level to encourage the health
care providers’ motivation for learning and collegial support
while suffering physical difficulties was beneficial. International
primary care organizations should maintain collegial dialogue to support
indigenization of family medicine, a process that adapts the principles
of family medicine into their own needs in their communities.
(Fam Med 2003;35(6):440-4.)
Innovations
in Family Medicine Education
A
Multidisciplinary, Learner-centered,
Student-run Clinic for the Homeless
Dana L. Clark, MD; Allegra Melillo, MD; David Wallace, PharmD; Stephen Pierrel,
PhD; David S. Buck, MD, MPH
Background and Objectives: Houston Outreach Medicine Education and Social Services
teaches students, in multidisciplinary teams, using the learner-centered model,
to provide primary health care to the homeless. Description: The founding and
operational aspects of this educational intervention are presented. Evaluation:
Student response to this service-learning program is assessed in terms of educational
value using a survey and an analysis of student reflections. Clinical service
activities are measured to demonstrate program efficacy. Conclusions: Student
participants, especially basic science medical students, value the program
due to its contributions to their professional and personal education, as well
as their increased understanding of biopsychosocial issues. Learners develop
empathy, compassion, and heightened social awareness.
(Fam Med 2003;35(6):394-7.)
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