Obstetric care in family practice residencies: a 5-year follow-up survey

BACKGROUND: The percentage of family physicians delivering babies decreased from 46% in 1978 to 32% in 1992. Some family practice leaders predicted that, by the turn of the century, training for family practice obstetrics would focus primarily on those planning to work in remote or rural settings. A 1993 study found three primary factors associated with an increased incidence of future maternity care. In 1997 the Residency Review Commission (RRC) stipulated that all family practice residencies have at least 1 family physician serve as an intrapartum attending physician for family practice resident deliveries. METHODS: Using an instrument similar to that used in 1993, we surveyed the directors of 462 family practice residencies in the United States. Sixty-four percent (295) of the program directors responded to one of two mailings. RESULTS: Compared with the survey published in 1993, program directors estimated a 16% increase in the number of residents who included obstetrics in their first practice after residency. Factors associated with increased obstetric participation included having only family physician faculty supervise uncomplicated deliveries and having family physician faculty who could perform other perinatal procedures. Programs that had 4 or more family physician faculty doing obstetrics and those that had more than 10 deliveries per month also produced more physicians who provided maternity care. Fifty-three percent of residencies that did not have family physician faculty attending deliveries before 1997 now meet this RRC requirement. CONCLUSIONS: This study shows that, according to their program directors' estimates, more family practice residents are including obstetrics in their first practice after residency compared with 5 years ago. The new RRC regulation was associated with more than 50% of previously noncompliant programs adding or retraining faculty who could attend resident deliveries within 12 months of the inception of the new policy.     

The University of Missouri Rural Obstetric Network: creating rural obstetric training sites for a university-based residency program

This paper describes a rural obstetric experience that was developed for a university-based family practice residency program and designed to increase the number of deliveries per resident, the number of graduates practicing in rural areas, and the number of graduates doing obstetrics. Rural hospitals can be a source of deliveries for residency training programs. This rural obstetric experience also offers more training months in a rural setting and more months training with family physicians.     

Length and content of family practice residency training

BACKGROUND: Family practice residency programs are based largely on a model implemented more than 30 years ago. Substantial changes in medical practice, technology, and knowledge necessitate reassessment of how family physicians are prepared for practice. METHODS: We simultaneously surveyed samples of family practice residency directors, first-year residents, and family physicians due for their first board recertification examination to determine, using both quantitative and qualitative methods, their opinions about the length and content of family practice residencies in the United States. RESULTS: Twenty-seven percent of residency directors, 32% of residents, and 28% of family physicians favored extending family practice residency to 4 years; very few favored 2- or 5-year programs. There was dispersion of opinions about possible changes within each group and among the three groups. Most in all three groups would be willing to extend residency for more training in office-based procedures and sports medicine, but many were unwilling to extend residency for more training in surgery or hospital-based care. Residents expressed more willingness than program directors or family physicians to change training. Barriers to change included disagreement about the need to change; program financing and opportunity costs, such as loss of income and delay in debt repayment; and potential negative impact on student recruitment. CONCLUSION: Most respondents support the current 3-year model of training. There is considerable interest in changing both the length and content of family practice training. Lack of consensus suggests that a period of elective experimentation might be needed to assure family physicians are prepared to meet the needs and expectations of their patients.     

Family physicians in university hospital intensive care units

Although physicians in most family practice residency programs hospitalize their patients at community hospitals, those in 21 programs in the United States hospitalize patients exclusively at university hospitals. Through a questionnaire mailed to directors of each of these programs, it was learned that family practice residency faculty have medical intensive care (ICU) privileges at 38 percent of these university hospitals. No family physicians had ever been denied ICU privileges at any of these hospitals. Mandatory consultations were reported by only a minority of programs. At 62 percent of these university hospitals, family physicians do not have ICU privileges. However, no family physician had every made a formal application for them. Intensive care patients at these hospitals were generally cared for by specialists and house staff in internal medicine or critical care.     

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.     

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.     

Investment in a Rural Residency Program: A Case Study

Rural hospitals have used numerous strategies over the past several decades to recruit and retain physicians. These have included providing physicians economic incentives, immigration status, professional and technical support and establishing rural training tracks (RTT) in family practice residency programs. This paper presents the experience of an isolated rural region in southwestern New York state that has employed each of these strategies in the past decade. Success as measured by the change in size of the medical staff, hospital operating margins, admissions and employment occurred only after the emphasis changed from meeting hospital needs to physician needs. Pivotal to this strategy was the nurturing and development of an RTT. Investment in the residency program required strong leadership to ensure the political, financial and operational commitment of its affiliated hospital. In addition, the RTT required an affiliation with a financially viable, full-service hospital, a strong on-site chief of service, family physicians who performed cesarean sections, midlevel providers and practitioners dedicated to the mission of teaching.     

Impact of Rural Training on Physician Work Force: The Role of Postresidency Education

Many innovative strategies have been developed over the years to improve the recruitment and retention of physicians in the shortage areas of rural America. These strategies have met with varying success. Postresidency education, or fellowship training, for family physicians is yet another strategy that has been developed for the same purpose. Most applicants have been interested in obstetrical and rural health fellowship programs as a means for preparing for rural practice. This paper describes these programs (demographics, funding, applicant pool, curriculum) and reviews their graduate outcomes (practice location after matriculation, clinical privileges). Twenty-nine obstetrical and nine rural health fellowships are currently operational in the United States. Fellows who complete a rural health fellowship have a higher tendency to locate in rural settings. Almost all graduates from obstetrical and rural health programs attain general hospital privileges in family practice, including low-risk obstetrics. A significant number of graduates from both types of programs attain privileges in high-risk and operative obstetrics as well. Fellowship training can play an integral role in the preparation of family physicians for rural practice.     

Follow-up on family practice residents' perspectives on length and content of training

BACKGROUND: The structure of family practice residency programs remains essentially unchanged from the model first proposed more than 35 years ago. Advances in medical technology and knowledge combined with increasing restrictions on resident work hours and decreasing medical student interest invite reconsideration of how family physicians are trained. METHODS: We resurveyed 442 third-year family practice residents who had participated in a prior study in 2000 to determine whether their opinions about the length and content of residency had changed and whether they would still choose to be a physician and a family physician. RESULTS: Thirty-seven percent of responding third-year residents favored extending family practice residency to 4 years. Compared as groups, there was relatively little change in opinion between first- and third-year residents. However, residents' individual responses about the settings and content areas for which they would be willing to consider extending training varied considerably between years 1 and 3. Personal characteristics did not seem to influence residents' opinions about length and content of training. Reasons for favoring a 4-year program and barriers to change were similar to those reported previously. Residents' commitment to medicine and family medicine was still strong and was not associated with their opinions about length of training. CONCLUSION: Although most surveyed residents favored a 3-year residency program, a substantial minority still supported extending training to 4 years, and the majority would still choose to enter family medicine programs if they were extended. Given a lack of consensus about specific content areas, family medicine should consider a period of experimentation to determine how to best prepare future family physicians.     

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.     

Training in Firearm Safety Counseling in Family Practice Residency Programs

The purpose of this study was to establish a national baseline regarding the prevalence of training of family practice residents regarding firearm safety counseling. A national survey of the residency directors at the 420 accredited family practice residency programs in the coterminous United States was used to assess the prevalance of training in firearm safety counseling, perceived effectiveness of such training, and perceived barriers to such counseling in residency programs. Program directors were sent a two-page questionnaire on firearm safety counseling activity in their programs and 71% responded. Few residencies (16%) had formal training in firearm safety counseling. The most common perceived barriers were no trained personnel (31%), too many other important issues (31%), not enough time (30%), and lack of educational resources (28%). Patient education materials (57%), video training programs (49%), and a curriculum guide (46%) were identified as resources, that would be most helpful in implementing a firearm safety counseling program. The results showed that formal training in firearm safety counseling is virtually absent from family practice residency training programs. This finding is not surprising given that less than 14% of the directors perceived firearm safety counseling would be effective in reducing firearm-related injuries or deaths and that research on effectiveness of such counseling is very limited.     

Graduate education in family practice: a ten-year review.

Assessment of the progress of graduate education in family practice after ten years shows that the original goals established for residency training in this specialty are being effectively met. There are now more than 360 approved family practice residencies in the United States with over 6,000 residents in training. Student interest in these programs has remained at a high level, and attrition has been low. Graduates of these programs have favored partnership and group family practice, and are well distributed in rural, suburban, and metropolitan areas. Heavy emphasis has been placed upon quality control mechanisms for both internal and external review of family practice residency programs. This paper outlines some concerns regarding the present status of family practice residencies, and suggests some directions for future development of these programs.     

Practice location as a function of medical school and residency location: implications for resident selection

Numerous studies have documented an association between the state in which a physician practices and prior education in that state. To determine whether this relationship exists for recent family practice residency graduates, 95 randomly selected programs in which residents completed training in 1979 were surveyed to obtain information regarding practice location and medical school location for their graduates. Seventy-nine percent of physicians completing residency and medical school in the same state also practiced in that state. Of those completing residency in a state other than that of their medical school, 43 percent stayed in the state of their residency to practice, and 22 percent returned to the state of their medical school. An analysis of the impact that a policy restricting house staff positions to in-state students would have on physician supply for the state reveals that only about 10 percent more physicians would be expected to start practice in a state if such a policy were implemented.     

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.     

House call practices among young family physicians

Once a major part of medical practice, physician house calls have declined in frequency over the years. Recently, it has been suggested that house calls are increasing. This study examined the current self-reported house call practices among recent graduates of family practice residency programs in the United States. A questionnaire was mailed to a cross-sectional, random national sample of 301 family physicians who are members of the American Academy of Family Physicians and who completed a residency between 1981 and 1986. There was a 66% response rate to three mailings, with 197 questionnaires analyzed. Sixty-two percent of the physicians reported they were making house calls. The majority (53%) made less than one house call per month. Fewer than 15% made house calls on a weekly basis. There was a downward trend by residency year in the percentage of physicians making house calls when comparing graduates from 1981 to 1986. House calls do not appear to be a significant part of the practice of young family physicians.     

Results of the 2002 National Resident Matching Program: family practice

The results of the 2002 National Resident Matching Program (NRMP) reflect a persistent decline of student interest in family practice residency training in the United States. Compared with the 2001 Match, six fewer positions (103 fewer US seniors) were filled in family practice residency programs through the NRMP in 2002, as well as 48 fewer (30 fewer US seniors) in primary care internal medicine, 1 fewer in pediatrics-primary care (8 more US seniors), and 45 fewer (45 fewer US seniors) in internal medicine-pediatric programs. In comparison, 43 more positions (70 more US seniors) were filled in anesthesiology, but 11 fewer (16 fewer US seniors) in diagnostic radiology, two "marker" disciplines that have shown increases over the past 3 years. Eight fewer positions (60 fewer US seniors) were also filled in categorical internal medicine while 99 fewer positions (142 fewer US seniors) were filled in categorical pediatrics programs, where trainees perceive options for either practicing as generalists or entering subspecialty fellowships, depending on the market. While the needs of the nation, especially rural and underserved populations, continue to offer opportunities for family physicians, family practice experienced a fifth year of decline through the 2002 NRMP. Many different forces, however, are impacting medical student career choices, including student perspectives of the demands, rewards, and prestige of the specialty, the turbulence and uncertainty of the health care environment, liability protection issues, and the impact of faculty and resident role models. The 2002 NRMP results may herald the leveling of recent trends away from family practice careers.     

Results of the 2003 National Resident Matching Program: family practice

The results of the 2003 National Resident Matching Program (NRMP) reflect a persistent decline of student interest in family practice residency training in the United States. Compared with the 2002 Match, 118 fewer positions (179 fewer US seniors) were filled in family practice residency programs through the NRMP in 2003, as well as 23 fewer (12 fewer US seniors) in primary care internal medicine, 20 fewer in pediatrics-primary care (11 fewer US seniors), and 23 fewer (34 fewer US seniors) in internal medicine-pediatric programs. In comparison, 40 more positions (14 more US seniors) were filled in anesthesiology and 8 more (8 more US seniors) in diagnostic radiology, two "marker" disciplines that have shown increases over the past 3 years. Sixty-seven more positions (but 148 fewer US seniors) were also filled in categorical internal medicine, while 107 more positions (33 more US seniors) were filled in categorical pediatrics programs, where trainees perceive options for either practicing as generalists or entering subspecialty fellowships, depending on the market. While the needs of the nation, especially rural and underserved populations, continue to offer opportunities for family physicians, family practice experienced continued decline though the 2003 NRMP. Many different forces, including student perspectives of the demands, rewards, and prestige of the specialty; the turbulence and uncertainty of the health care environment; liability protection issues; and the impact of faculty and resident role models, are impacting medical student career choices. The 2003 NRMP again confirms the trend away from family practice and primary care careers.     

THE UNIVERSITY OF WASHINGTON WAMI PROGRAM: 25 YEARS OF EXPERIENCE WITH MANPOWER SHORTAGES IN RURAL AREAS

ABSTRACT: The University of Washington is the only United States medical school serving the health care education needs of Washington, Alaska, Montana and Idaho (WAMI) and has evolved a unique set of partnerships to address this predominantly rural region of the United States. Three specific aspects of this program are relevant to Australia's rural health needs: (i) 'pipeline' efforts that groom rural and minority students long before medical school in order to keep them in the potential applicant pool; (ii) a decentralized medical school curriculum that provides repetitive training opportunities in rural and community-based settings; and (Hi) special residency rotations, physician assistant programs and rural hospital support all of which train and maintain health care providers in rural remote settings.     

The effect of a rural preceptorship during residency on practice site selection and interest in rural practice

Rural areas of the United States face serious shortages in health care personnel. This report evaluates the effect of a rural preceptorship during the second or third year of a family practice residency on interest in rural practice and on practice site selection. A majority of participants (n = 123) felt that this experience influenced their choice of a practice site. Furthermore, a large majority felt that it increased their interest in rural practice opportunities. Rural preceptorships during residency are a timely solution to increase the number of family physicians interested in rural practice.