Why pregnancy care should be an essential part of family medicine training

Some family medicine educators are arguing to eliminate pregnancy care as a required component of family medicine training since the majority of family physicians no longer perform deliveries, and many programs are having increasing difficulties in meeting this training requirement. The primary benefit of pregnancy care training is not to produce family physicians who all perform deliveries but to produce family physicians who are competent to provide comprehensive primary care to women and girls, including routine and preventive reproductive care. The training in pregnancy care helps to differentiate family medicine residencies from other primary care training programs by facilitating competency in a wide range of reproductive health care for nonpregnant women and for the primary nonreproductive health care of pregnant and postpartum women. Residencies offering pregnancy care services also enhance their ability to train residents in child care. Family medicine should continue to strive to improve this aspect of residency training instead of abandoning it.     

Community medicine in the training of family physicians.

Family practice residency programs are encouraged to include community medicine training in their curriculum, but there is little agreement as to what community medicine is or what would constitute appropriate training. Community medicine is most commonly defined as a discipline concerned with the identification and solution of health care problems of communities or other defined populations. The inclusion of training experiences in the identification and solution of health care problems of communities has two basic advantages for family practice residency programs: it fosters a contextual approach in the care of individual patients and it builds knowledge and skills for those who will work with communities in future practices. An example of curricular content is included. A survey was conducted in order to determine what residency programs teach in the field of community medicine. The results show that few of the responding programs include the areas which most clearly relate to community medicine. It is hoped that the report of these results, the rationale presented for including community medicine in the training of family physicians, and the suggested outline of curricular content will further encourage and assist family practice residency programs to incorporate such training in their curricula.     

Family Medicine Spokane Rural Training Track: 24 years of rural-based graduate medical education

Twenty percent of the US population lives in rural communities, but only about 9% of the nation's physicians practice in those communities. There is little doubt that the more highly specialized physicians are, the less likely they are to practice or settle in rural areas. There is clearly a population threshold below which it is not feasible for specialist (in contrast to generalist) physicians to pursue the specialty in which they have trained. Much of rural America falls below that threshold. This leaves large geographic areas of America to the primary care physician. The proportional supply of family physicians to specialists increases as urbanization decreases. Family physicians are the largest single source of physicians in rural areas. Family medicine residency programs based in rural locations provide a critical mechanism for addressing rural primary care needs. Graduates from rural residency programs are three times more likely to practice in rural areas than urban residency program graduates. There are two primary goals of training residents in rural areas: producing more physicians who will practice in rural areas and producing physicians who are better prepared for the personal and professional demands of rural practice. Rural Training Tracks, where the first year of residency is completed in an urban setting and the second and third years at a rural site (1-2 model), initially proposed by Family Medicine Spokane in 1985, have been highly successful in placing and maintaining more than 70% of their graduates in rural communities. Similar and modifications of the "Spokane RTT model" have been established around the country. Now, more than 24 years of educational experience has been accumulated and can be applied to further development of these successful family medicine residency programs.     

The Need to Train Physicians for Rural Primary Health Care in Latin America: Some Family Medicine Experiences*

ABSTRACT: Training strategies to prepare physicians for rural primary care generally have not been a feature of medical education in Latin America. The emergence of family medicine as a specialty discipline has resulted in a number of primary care educational initiatives which are designed to give students or residents the knowledge and skills necessary to practice in rural settings. Specific programs in Mexico, Colombia, Chile, and Argentina are identified and discussed. These programs were selected because they raise a number of educational and manpower planning issues which teachers of family medicine and rural primary care need to address if the long-term viability of these programs is to be achieved. These issues include: the role of the community as an educational laboratory, the supervision of community-based learning experiences, the development of strong clinical and community health promotion skills, the reinforcement of positive primary care learning throughout training, and the development of rural health role models. Manpower planning issues to be addressed include: developing a more precise identity for the primary care physician, a re-examination of the pasantia or year of required community service, developing closer ties between the medical schools and the Ministries of Health and other institutional employers of physicians, and encouraging successful programs to share their experiences with others.     

Obstetric care among family physicians in Pennsylvania. Trends, association with residency training, and policy implications

A study was designed to investigate the status of obstetric practice by Pennsylvania family physicians and its relationship to family practice residency training. A 50% probability sample of all family and general physicians and of all graduates of Pennsylvania family practice residency programs was surveyed by mail. Ten percent of Pennsylvania family physicians and general practitioners reported currently practicing obstetrics, 44% of whom said they planned to stop within 3 years. Telephone survey information from nonresponders suggests that even fewer (5%) of the state's family physicians may actually be practicing obstetrics. Family practice residency training, postresidency obstetric training, and small community size were the best predictors of current obstetric practice. Family physicians in the smallest communities, however, were also those most likely to be planning to stop, and graduates of residency programs were increasingly choosing not to practice obstetrics. Cost of liability insurance and fear of lawsuits were primary reasons cited for stopping obstetrics. Family physicians have been major providers of obstetric care in the nation's rural areas. Now, increasingly firm evidence that fewer family physicians are practicing obstetrics signals increasing shortages in obstetric care for women in rural communities. Changes in the practice climate and obstetric training programs for family physicians seem essential to help reverse these trends.     

The Rural Physician Workforce in Florida: A Survey of US- and Foreign-Born Primary Care Physicians

CONTEXT: To meet the challenge of primary care needs in rural areas, continuing assessment of the demographics, training, and future work plans of practicing primary care physicians is needed. PURPOSE: This study's goal was to assess key characteristics of primary care physicians practicing in rural, suburban, and urban communities in Florida. METHODS: Surveys were mailed to all of Florida's rural primary care physicians (n = 399) and a 10% sampling (n = 1236) of urban and suburban primary care physicians. FINDINGS: Responses from 1000 physicians (272 rural, 385 urban, 343 suburban) showed that rural physicians were more likely to have been raised in a rural area, foreign-born and trained, a National Health Service Corps member, or a J-1 visa waiver program participant. Rural physicians were more likely to have been exposed to rural medical practice or living in a rural environment during their medical school and residency training. Factors such as rural upbringing and medical school training did not predict future rural practice with foreign-born physicians. Overall, future plans for practice did not seem to differ between rural, urban, and suburban physicians. CONCLUSIONS: Recruiting and retaining doctors in rural areas can be best supported through a mission-driven selection of medical students with subsequent training in medical school and residency in rural health issues. National programs such as the National Health Service Corps and the J-1 visa waiver program also play important roles in rural physician selection and should be taken into account when planning for future rural health care needs.     

Geriatric medicine training for family practice residents in the 21st century: a report from the Residency Assistance Program/Harfford Geriatrics Initiative

Increasing the quality and quantity of geriatric medicine training for family practice residents is a particular challenge for community-based programs. With support from the John A. Hartford Foundation of New York City, the American Academy of Family Physicians (AAFP) implemented in 1995 a multi-part project to improve the amount and quality of geriatric medicine education received by family practice residents. This report summarizes the initial results of the regional geriatric medicine curriculum retreats for residency directors. The goals of the retreats were to build recognition among the residency directors of the skills that future family physicians will require to be successful providers of primary care to older adults and to allow the residency directors to identify and develop solutions to barriers to improving geriatric medicine training for residents. Forty-six program directors participated in the three retreats between February 2000 and February 2001. The participants represented 52 programs and rural tracks in all geographic regions, small and large programs, and urban and rural settings. The program directors developed a consensus on the geriatric medicine knowledge, skills, and attitudes that should be expected of all family practice residency graduates; developed a list of basic, required educational resources for each family practice residency program; and proposed solutions to common obstacles to successful curriculum development.     

Family medicine and psychosocial knowledge: how many hats can the family doctor wear?

The paper examines the impact of teaching family physicians psychosocial skills and knowledge during their residency training in family medicine. The idea put forth by the family practice profession that family physicians are trained to treat their patients' biological, as well as psychosocial problems, is important to the social work profession since social workers have had primary responsibility in treating patients' psychosocial problems in the health care arena in the United States from 1904 until now. In order to learn about the effect of adding psychosocial knowledge to the family practitioner's training curricula, the author conducted an exploratory and comparative study to see if family practitioners had any more psychosocial knowledge than other primary care physicians. No significant differences were found. Implications of the study for family medicine and social work, primary health care, and social/health policy are discussed.     

The Role of the Medical School in Rural Graduate Medical Education: Pipeline or Control Valve?

Although rural-based graduate medical education is critically important in the training of competent rural family physicians, the number of physicians selecting these programs is highly dependent on what happens earlier in the pipeline, i.e., during medical school. Using the experience and outcomes research from Jefferson Medical College's Physician Short-age Area Program, as well as from published literature describing six other medical school programs with similar goals, this paper addresses the important role of these programs in substantially increasing the number of physicians interested in rural family practice. Although each of these programs differs in its structure, all contain three core features: a strong institutional mission; the targeted selection of students likely to practice in rural areas, predominantly those with rural backgrounds; and a focus on primary care, especially family practice. Outcomes show that all seven programs have been highly successful. Medical schools, therefore, can have a major impact on the number of rural physicians they produce by acting not only as a pipeline or conduit to residency programs, but also as a control valve, beginning as early as the admissions process. In order to maximize their impact on the supply and training of rural family physicians, rural residency programs should understand, support, collaborate with and help develop medical school programs whose mission is to provide rural physicians.     

Training and application of community-oriented primary care (COPC) through family medicine in Catalonia, Spain

The community-oriented primary care (COPC) approach, implemented in various countries by family physicians, general practitioners, and other primary care workers, integrates clinical medicine with aspects of public health. A process of 20 years of training health professionals (40-hour workshop) by the professional association of family physicians (Catalan Society of Family and Community Medicine), training family medicine residents and giving support to health teams in Catalonia, Spain, generated a present group of 30 primary care teams involved in community health projects. This paper describes and analyzes factors related to changes in the health system, the role of family medicine in Spain, and to features of the COPC approach and its training methods as elements that narrow the gap between training and practice.     

Influence of residency training on occupational medicine practice patterns

OBJECTIVES: A relatively high proportion of occupational medicine (OM) specialists have not had formal residency training in OM. Members of the Western Occupational and Environmental Medicine Association, a professional organization of OM specialists, completed a postal questionnaire (160 of 561 members). METHODS: Educational background, practice setting, practice activities, and skills considered relevant were compared between those with and without formal training. RESULTS: Both groups had considerable focus in clinical care, musculoskeletal medicine, and workers' compensation. However, those with formal training practice in a broader variety of settings were less likely to have practiced another specialty, and used additional skills (toxicology, industrial hygiene, and epidemiology) in their practices. Formal education appears to create a greater diversity of skills and opportunities, but it does not appear to create a group of physicians disinterested in "front-line" occupational medicine practice. CONCLUSIONS: The data support the need for formal residency programs but also highlight the importance of access to formal training for midcareer physicians.     

Contractual arrangements between residency programs and HMOs.

BACKGROUND. Although one out of seven health maintenance organizations (HMOs) is directly involved in graduate medical education (GME), either as an accredited sponsoring organization or through a contractual agreement with an academic medical center or teaching hospital to serve as an ambulatory rotation site, relatively little is known about the extent to which HMOs have provider contracts with faculty or residents of GME programs. Such provider contracts are not agreements to collaborate on the education of residents, but rather contractual arrangements under which individual physicians or groups (who happen to be residents or faculty) agree to provide services to HMO enrollees in return for some form of compensation. METHODS. In 1990, the Group Health Association of America conducted a survey of a sample of residency training programs in family medicine, internal medicine, and pediatrics to ascertain the extent to which (1) residents and faculty of residency training programs are participating physicians in HMOs; and (2) HMO enrollees are serving as the patient base for GME in ambulatory settings. RESULTS. Overall, 42% of the residency program respondents indicated that they contract with HMOs to provide services to enrollees. Nearly two thirds (64%) of family practice programs have provider contracts as compared with 28% of pediatrics programs and 24% of internal medicine programs. Provider contracts with independent practice associations are by far the most common, followed by group, network, and staff model contracts, in that order. CONCLUSIONS. It is apparent that provider contractual arrangements between HMOs and primary care residency programs are quite common, especially in the area of family practice. These contractual arrangements have probably resulted in a more predictable and stable patient revenue base for residency programs. The long-term effects on provider practice styles and the financing of graduate medical education are less clear.     

Primary care residents and the management of hypercholesterolemia

A survey of primary care residents' attitudes, beliefs, and knowledge and a medical record audit were used to assess barriers to appropriate detection, identification, and management of hypercholesterolemia. Previous studies have focused on either self-reports or audits alone. This study compares survey results to recorded clinical performance. Family practice and internal medicine residents were compared to determine if previous findings were specialty-specific. The results of the survey indicate that, even prior to the publication of the National Cholesterol Education Program, residents demonstrated positive attitudes and appropriate knowledge of risk levels, in contrast with previous reports on practicing physicians. The medical record audit, however, showed that residents were not providing care that approximated their own recommendations for hypercholesterolemia management. Results of the survey and audit demonstrated little or no difference between specialty groups. The results indicated that training in management skills and reducing practice barriers are important to improve resident physicians' management of patients with hypercholesterolemia. The use of a survey and audit provide a useful needs assessment for designing educational programs.     

A plea for an initiative to strengthen family medicine in public health care services of developing countries.

An analysis of standards for the best practice of family medicine in Northern European countries provides a framework for identifying the difficulties and deficiencies in the health services of developing countries, and offers strategies and criteria for improving primary health care practice. Besides well-documented socioeconomic and political problems, poor quality of care is an important factor in the weaknesses of health services. In particular, a patient-centered perspective in primary care practice is barely reflected in the medical curriculum of developing countries. Instead, public sector general practitioners are required to concentrate on preventive programs that tackle a few well-defined diseases and that tend to be dominated by quantitative objectives, at the expense of individually tailored prevention and treatment. Reasons for this include training oriented to hospital medicine and aspects of GPs' social status and health care organization that have undermined motivation and restricted change. A range of strategies is urgently required, including training to improve both clinical skills and aspects of the doctor-patient interaction. More effective government health policies are also needed. Co-operation agencies can contribute by granting political protection to public health centers and working to orient the care delivered at this level toward patient-centered medicine.     

The cost-effectiveness of training US primary care physicians to conduct colorectal cancer screening in family medicine residency programs

BackgroundDemand for a wide array of colorectal cancer screening strategies continues to outpace supply. One strategy to reduce this deficit is to dramatically increase the number of primary care physicians who are trained and supportive of performing office-based colonoscopies or flexible sigmoidoscopies. This study evaluates the clinical and economic implications of training primary care physicians via family medicine residency programs to offer colorectal cancer screening services as an in-office procedure.MethodsUsing previously established clinical and economic assumptions from existing literature and budget data from a local grant (2013), incremental cost-effectiveness ratios are calculated that incorporate the costs of a proposed national training program and subsequent improvements in patient compliance. Sensitivity analyses are also conducted.ResultsBaseline assumptions suggest that the intervention would produce 2394 newly trained residents who could perform 71,820 additional colonoscopies or 119,700 additional flexible sigmoidoscopies after ten years. Despite high costs associated with the national training program, incremental cost-effectiveness ratios remain well below standard willingness-to-pay thresholds under base case assumptions. Interestingly, the status quo hierarchy of preferred screening strategies is disrupted by the proposed intervention.ConclusionsA national overhaul of family medicine residency programs offering training for colorectal cancer screening yields satisfactory incremental cost-effectiveness ratios. However, the model places high expectations on primary care physicians to improve current compliance levels in the US.     

Physician perspectives on routine pregnancy intention screening and counseling in primary care

ObjectivesTo assess factors associated with routine pregnancy intention screening by primary care physicians and their support for such an initiative.Study designWe conducted a cross-sectional survey study of 443 primary care physicians in New York State. We performed multivariable logistic regression analyses of physician support for routine pregnancy intention screening and implementation of screening in the last year. Predictors included in the models were physician age, sex, specialty, clinic setting, and, for the outcome of support for screening, experience with screening in the last year.ResultsIn this convenience sample, the vast majority of respondents from all specialties (88%) felt pregnancy intention screening should be routinely included in primary care, with 48% reporting that they routinely perform such screening. The preferred wording for this question was one which assessed reproductive health service needs. In multivariable analyses, internal medicine physicians were less likely than family medicine physicians to have provided routine pregnancy intention screening (aOR = 0.15, 95% CI 0.09, 0.25). Only 8% of the sample reported they required more training to implement pregnancy intention screening, but more reported needing training prior to contraceptive provision (17%), contraceptive counseling (16%), and preconception care (15%). More internal medicine and other types of doctors cited a need for this additional training than family medicine physicians.ConclusionsMost responding primary care physicians supported routine integration of pregnancy intention screening. Incorporating additional training, especially for internal medicine physicians, in contraception and preconception care counseling is key to ensuring success.Implications statementResponding primary care physicians supported routine inclusion of reproductive health needs assessment in primary care. Primary care may become increasingly important for ensuring access to a full range of reproductive health services. Providing necessary training, especially for internal medicine physicians, is needed prior to routine inclusion.     

Family physicians and the future of fee-for-service payment plans

The mechanisms by which health care providers in the United States are reimbursed for their services are undergoing dynamic and rapid changes. Traditional fee-for-service payment schemes as the predominant reimbursement methods are declining and are being supplanted by a plethora of different schemes that incorporate prepayment as the mode of compensation for service. A number of trends over the past decade predict that this transference to prepayment will continue in the future and will have a profound impact on the future practice of family medicine. It is important for family medicine educators and practicing family physicians to understand these market forces and trends so they will be better able to alter their training programs and future practices to meet future needs.     

Defining Competencies and Performance Indicators for Physicians in Medical Management

The recent and profound changes in the American health care delivery system have created a need for physicians who are trained and willing to assume a high level of responsibility for managing evolving health care organizations. Yet most physicians receive no formal training in medical administration and management because changes in medical school and residency education have lagged behind changes in clinical practice and reimbursement. To avoid haphazard approaches and unnecessary duplication of resources, it is important for physicians involved in managerial medicine to collectively identify competencies in this area needed in the marketplace. The American College of Preventive Medicine (ACPM), with funding from the Health Resources and Services Administration (HRSA), undertook an effort to identify competencies essential for physicians who will fill leadership roles in medical management. Like ACPM’s earlier effort to develop core competencies in preventive medicine, this project drew upon the theoretical model of competency-based education. This article describes the strategy we followed in reaching consensus among a diverse group of physician executives and preventive medicine residency program directors, and includes the list of medical management competencies and performance indicators developed. Recurrent issues that can sidetrack competency development projects are also presented as well as suggestions for overcoming them. The competencies can serve as a framework for expanding current core preventive medicine training in management and administration and for developing new training programs to equip physicians with the special expertise they will need to provide management leadership within the changing landscape of health care delivery.     

Colposcopy practice and training in family practice residency programs.

BACKGROUND: The potential growth of colposcopy as a family medicine procedural skill is directly related to the training currently offered to family practice residents. To define whether these skills are being adequately offered to physicians who want to perform this procedure for their patients, a study was designed to investigate the current status of colposcopy practice and training in family practice residency programs. METHODS: A 16-item survey sent to 356 family practice residency directors in the United States included items concerning colposcopy practice, training, educational programs and strategies, colposcopy coordinator educational background, and colposcopic resource materials and equipment. RESULTS: Surveys were returned from 204 (57 percent) family practice residencies. Colposcopy was performed at 45 percent of the residencies that responded. Ninety-six percent of the respondents who did not perform colposcopy believed colposcopy is a procedure that should be performed by family physicians. Clinical teaching and supervision was the most common method of resident training (74 percent). Colposcopy training coordinators were usually family physicians (72 percent), primarily trained by gynecologists. Assistance with implementing a colposcopy training program was requested by 85 percent of those programs presently not performing colposcopy. CONCLUSIONS: This study indicates that there are opportunities for further development of colposcopy practice and training in family practice residencies.     

The underrepresented in graduate medical education and medical research

There is a perception that the career options open to medical school graduates who are members of minority groups are restricted. This perception relates especially to those postgraduate medical training programs that have not traditionally encouraged or had significant minority participation. Data were therefore sought to determine whether this perception was well founded. Recent reports show the strikingly low numbers of minorities on medical school faculties and in administrative positions in spite of efforts to fill such positions. Information on the specialties of practicing minority physicians is limited, but accurate figures are available on the participation of minorities in various specialty postgraduate training programs. For instance, during recent years, 50 to 60 percent of all black residents have been trained in internal medicine, pediatrics, general surgery, and obstetrics and gynecology. Further studies are needed to document or disprove the conception that minority physicians have less access than other physicians to certain careers in the delivery of health care and education. In the interim, efforts should be continued to encourage minority physicians not only to seek preparation for community primary care practice, but also for professional participation in academic careers of other specialties (and subspecialties), in biomedical and clinical research, and in health care administration. The ability to enter these diverse careers is most often determined by the opportunities available at the time of completion of medical school education. Therefore, those involved in graduate medical education should address the challenge of providing opportunities for the proportionate representation of minorities in all aspects of medical care and medical education.