February 2003, Vol. 35, No. 2

What to Do When Faced With the Closure of a Family Practice Residency
Perry A. Pugno, MD, MPH, CPE

The turbulent health care environment, combined with recent reductions in federal support for graduate medical education, has threatened the viability of many residency programs. Several family practice programs are in the process of struggling for survival, while others have been forced to close. A new Residency Assistance Program (RAP) consultation has been developed to help programs “justify their existence” to sponsoring institutions. This paper discusses the signs that a program’s viability may be in jeopardy and offers recommendations to reduce the risks of closure. For those residencies forced to cease operations, 11 recommendations are provided to minimize the negative impact of closure on the program’s residents, faculty, and staff. Those include steps to assure that current residents receive full credit for the training time completed and the importance of notifications to the Residency Review Committee for Family Practice, the American Board of Family Practice, and the Association of Family Practice Residency Directors. Decisions must be made about whether the option exists to permit current residents to complete their training in the same facility or whether assistance is available to facilitate resident transfers to other programs. Open and honest communication among affected parties is emphasized to minimize the emotional consequences of such an important event.

(Fam Med 2003;35(3):170-3.)

A Maternal and Child Health Curriculum for Family Practice Residents: Results of an Intervention at the University of North Carolina
Margaret Helton, MD; Bron Skinner, PhD; Clark Denniston, MD

Background and Objectives: There has been a significant reduction in the number of family physicians who provide pregnancy care. This study examines the effects of an educational intervention at a university- based family practice residency. The intervention was designed to increase the number of graduates who include prenatal care or deliveries in their practices. Methods: The curriculum in pregnancy care was expanded to include a teaching service, better role modeling by family medicine faculty, more deliveries, stronger didactics, breast-feeding and child health services, and greater collaboration with other health care settings and professionals. Results: The intervention increased the average percentage of residents who included prenatal care or deliveries in their practices after graduation from 27.5% to 52%. Conclusions: This educational intervention increased the number of family practice residency graduates who plan to include prenatal care or deliveries in their practices.

(Fam Med 2003;35(3):174-80.)

Defining Differences in the Instructional Styles of Community Preceptors
Andrea Manyon, MD; Judith Shipengrover, PhD; Denise McGuigan, MSEd; Mark Haggerty; Paul James , MD; Andrew Danzo

Background and Objectives: Variability exists in the instructional experiences of medical students in clinical settings. As relationships between community-based physicians and medical students expand, it is important to promote instructional styles that enhance teaching and learning. This study identified attitudes and approaches toward teaching that distinguish preceptors with high student ratings from those with lower ratings. Methods: Interviews were conducted with a purposive sample of 14 preceptors who had received either high or low scores from first-year students on the MedEd IQ,® a standardized tool for assessing ambulatory clinical training experiences. Transcripts were analyzed using a qualitative approach. Results: High-scoring preceptors were distinguished by six attributes: welcoming novice clinicians as legitimate participants in a community of practice, creating a central role for students in patient care and teaching, regularly engaging students in self-reflection to monitor their progress, helping students discover learning opportunities in routine patient encounters, using feedback to shape rather than evaluate student performance, and creating an environment where novices felt comfortable practicing new skills with patients. Conclusions: The results suggest that high-scoring preceptors provide a decidedly different experience through their approach to the challenge of training inexperienced students. These findings have implications for preceptor selection criteria and faculty development curricula.

(Fam Med 2003;35(3):181-6.)

Facilitating Academic Institutional Change: Redefining Scholarship
Dona L. Harris , PhD; Debra A. DaRosa, PhD; Philip L. Liu, MD; Robert B. Hash, MD

Background and Objectives: Academic institutions are typically resistant to change. Redefining scholarship is an important issue for academic health care institutions. This study examines the change process at institutions that have attempted to change the definition of scholarship. Methods: Five medical schools were identified that had recently redesigned their promotion and tenure systems based on expanded definitions of scholarship. Interviews were conducted with a key leader in this effort. The interviews were designed to identify the forces and barriers involved in change, activities designed to secure faculty “buyin,” factors needed to sustain change, and advice that would help others who might be considering such an effort at their academic health centers. We organized the results of the interviews within a change leadership and management model. Results: The responses to the survey questions fit well into the change model. Many of the responses were felt to be applicable to multiple stages of the change model. Conclusions: The leaders of change from the study institutions, either by intention or intuition, identified key factors of their change process that fit well with the study model. Change leaders should include plans that follow an established model for institutional change in their strategy to change the definition of scholarship at their institution.

(Fam Med 2003;35(3):187-94.)

A Physician Peer Support Writing Group
Stefan C.W. Grzybowski, MD, MClSc; Joanna Bates , MD; Betty Calam, MD, MClSc; Janet Alred; Ruth Elwood Martin, MD; Rodney An drew, MD; Launette Rieb, MD, MSc; Susan Harris , MD; Carl Wiebe, MD; Eva Knell, MD; Samara Berger, MHSc

Background and Objectives: Barriers to publication can be overcome through a peer support writing group in an academic department of family practice. This study describes the experience and outcomes of a writing group in a family practice department. Methods: A writing group was established to provide collaboration in identifying potential research and/or writing projects, to assist individual faculty to complete unfinished work for submission, to match journals appropriate to the individual group member’s work, and to provide peer support for faculty members through attention to group process. Resource materials included instructions for authors for various journals and writing support literature. Minutes were taken at each meeting, and the manuscripts presented were tracked. Individual publication records in CVs and citations in Index Medicus were used to generate pre-group and post-group publication records for group participants and nonparticipants. Results: The writing group met 23 times in 36 months. Attendance ranged from 3 to 10 participants. Fifty writing projects were discussed, and 12 of the discussed manuscripts were published in indexed journals. The seven most frequent attendees increased their publications as first author from one publication over the 3 years prior to the writing group to 10 publications over the first 3 years of the writing group. Comparison of the attendees’ publication records with nonparticipant members of the department demonstrated an increase in publication success for participants. Conclusions: A peer support writing group, emphasizing group process and respectful collaboration, has increased the publication frequency of faculty in a Canadian department of family practice.

(Fam Med 2003;35(3):195-201.)

Increases in Resident and Faculty Computing Skills Between 1998 and 2001
Anthony F. Jerant, MD; A. David Matian, DO; Richard G. Lass lo, MD, MS

Background and Objectives: Following a 1998 survey, we hypothesized that family practice residents would soon demand more advanced informatics and computer training than faculty could provide. We repeated the survey in 2001 to test our hypothesis. Methods: We surveyed 97 first-year medical students, 46 family practice residents, and 18 family medicine faculty at our institution. We compared responses among groups and within groups since 1998. Results: Significantly more respondents owned a computer in 2001 than in 1998. E-mail and Internet use increased dramatically for all groups. Students and faculty had significantly greater confidence in their general computer abilities than residents did in 2001, but third-year residents’ confidence had increased significantly since 1998. Respondents cited inadequate computer resources as the most important barrier to effective computer use. Conclusions: Resident and faculty self-assessed computer skills have increased substantially at our program since 1998. These increases appear due to the current ubiquity of computers in society and improvements in device functionality and ease of use rather than curricular activities. Few residents and faculty need the basic computer training recommended in curricular guidelines. Residency programs should maintain up-to-date computer resources and consider providing selective advanced computer skills training.

(Fam Med 2003;35(2):202-8.)

Panic-related Outcomes in Patients With a Personal Physician
David Katerndahl, MD, MA

Background and Objectives: Although having a regular source of care is associated with positive health behaviors, its effect in specific disorders is not known. This study assessed differences in outcomes of patients with panic attacks, including symptoms, health care utilization, and treatment for panic symptoms based on the presence and specialty of a self-defined personal physician. Methods: In this community- based study, 97 subjects with Diagnostic and Statistical Manual, Third Edition, Revised (DSM-IIIR) panic attacks were interviewed concerning total and recent health care utilization for panic symptoms, total and current treatment for panic symptoms, and panic-related outcomes such as quality of life, psychiatric symptoms, work disability, substance abuse, and perceived control. Results: Although the absence of a personal family physician was not related to outcomes, the specialty of the personal physician was associated with significant differences in recent health care utilization and treatment for panic and in panic-related outcomes. Having a mental health provider was associated with more utilization and treatment but worse outcomes. However, such differences could generally be explained by differences in preexisting psychiatric disorders and the severity of panic symptoms. Conclusions: Compared with having a mental health provider, having a family physician was associated with fewer recent ambulatory visits, particularly to mental health settings, and less-frequent current use of prescription, over-the-counter, or illicit drugs for panic. Yet, when corrected for panic severity and prior mental disorders, there was no difference in these outcomes.

(Fam Med 2003;35(3):209-14.)

EKG Arrhythmia Recognition: A Third-year Clerkship Teaching Experience
Jamee Lucas , MD; Scott McKay, MD; Elizabeth Baxley, MD

Background and Objectives: This report describes a curricular experience designed to improve EKG arrhythmia recognition skills in third-year medical students in a required family medicine clerkship. Intervention: An innovative 1-hour seminar that teaches a systematic approach to EKG arrhythmia recognition was added to the family medicine clerkship. Students were tested on ability to identify arrhythmias at the end of the clerkship. Scores were compared between the intervention group and a control group consisting of students in the year before the seminar was added. Results: Students who received the didactic session recognized more arrhythmias correctly. Conclusions: This systematic approach to arrhythmia recognition improves the ability of third-year medical students to interpret EKGs.

(Fam Med 2003;35(3):163-4.)