Recognition of depression by internal medicine residents

We studied the ability of internal medicine residents to recognize depressive symptoms in a population of lower socio-economic primary care patients. Four hundred twenty patients completed the short form of the Beck Depression Inventory (BDI). Simultaneously, the resident caring for the patient estimated the degree of depression for each patient. One-fourth of the patients scored at or above the moderately depressed level on the BDI and the residents rated 23 percent of their patients as at least moderately depressed. However, the accuracy of the residents' assessment of his or her individual patient was poor (correlation=0.42, sensitivity=0.46, specificity=0.84). Patients with a scored higher on the BDI and were given higher ratings of depression. No other pre-existing medical condition was significantly associated with a higher or lower BDI score. The amount of alcohol consumed and the amount smoked, were both associated with higher BDI scores. Residents varied in their sensitivity to their patients' BDI scores. Some showed high agreement with BDI scores, others low. There were no specific resident characteristics (e.g. year of training, resident gender) that could explain this variability. Patients with a history of depression were given lower resident ratings compared to other patients and patients with a history of depression were given lower resident ratings than predicted by their BDI scores. Residents' ability to accurately diagnose and treat depression in the underprivileged primary care patient can be facilitated by the institution of depression screening in the ambulatory clinic.Robert J. Sliman is assistant professor of medicine, David Jarjoura is associate professor of biostatistics in the division of community health sciences and Andre J. Ognibene is professor and chairman of the department of medicine, all at the Northeastern Ohio Universities College of Medicine, Rootstown, Ohio 44272. Thomas A. Donohue is a student at Case Western Reserve University School of Medicine, Cleveland, Ohio.     

There's no place like home: evaluating family medicine residents' training in home care

This study examined residents' experiences in a physician home visit program and their attitudes toward working with older patients in a home setting. In-depth personal interviews were conducted with all second and third year residents in a family medicine residency program (n = 17). Most residents expressed positive attitudes about caring for patients in their homes. Residents said home visits allowed them to provide better care, and enhanced their assessment skills and understanding of community services. We identified a lack of coordination and consistency in several areas, including home visit assessments and the role of physician preceptors. The need for formal training to identify and treat elder abuse was also identified. Participation in a home visit program appears to be an effective learning experience for residents, and helps residents to understand the needs of older people living in the community.     

Pediatric AIDS: Are Physicians Ready?

This study assessed medical residents' perceptions of their overall competence to provide primary care to pediatric AIDS patients. On a 7-point Likert scale, residents in pediatric (n=260) and family practice (n=161) training programs across the United States rated their educational preparedness and training experiences in AIDS care in 9 areas. Respondents were predominantly White (74%) and female (53%). completing their 3rd year of training (94%) at a university-affiliated program (87%), with a mean age of 31. Overall, 98% of the residents had treated HIV-infected and AIDS-infected patients. Repeated-measures multivariate analyses of variance were used to identify significant differences between the two specialties on 9 areas of curricular training and two patient age groups (pediatric and adolescent). Perceptions of the residents concerning their preparedness to diagnose HIV and AIDS treat AIDS-related illnesses, treat AIDS patients and their overall level of competence to provide AIDS primary care for pediatric and adolescent patients is discussed. There appears to be a need for further AIDS-related educational experiences in residency training programs.     

A comparison study of career satisfaction and emotional states between primary care and speciality residents

OBJECTIVE: To evaluate career satisfaction, emotional states and positive and negative experiences among residents in primary care and speciality programmes in 1 academic medical centre prior to the implementation of the Accreditation Council for Graduate Medical Education's (ACGME) duty hour requirements. DESIGN: Cross-sectional survey. MEASUREMENTS: All 581 residents in the academic health centre were asked to participate voluntarily in a confidential survey; 327(56%) completed the survey. RESULTS: Compared to their primary care colleagues, speciality residents had higher levels of satisfaction with career choice, feelings of competence and excitement, lower levels of inferiority and fatigue and different perceptions of positive and negative training experiences. However, 77% of all respondents were consistently or generally pleased with their career choices. The most positive residents' experiences related to interpersonal relationships and their educational value; the most negative experiences related to interpersonal relationships and issues perceived to be outside of residents' control. Age and training level, but not gender also influenced career satisfaction, emotional states and positive and negative opinions about residency. CONCLUSIONS: Less satisfaction with career choice and more negative emotional states for primary care residents compared to speciality residents probably relate to the training experience and may influence medical students' selections of careers. The primary care residents, compared to speciality residents, appear to have difficulty in fulfilling their ideals of professionalism in an environment where they have no control. These data provide baseline information with which to compare these same factors after the implementation of the ACGME duty hours' and competency requirements.     

Factors influencing patients' choice of primary medical doctors

This study investigated factors that influence adult patients' choice of primary care physicians and aimed to determine whether patients know the difference between internal medicine and family medicine. One thousand patients who had seen their primary care physician in either the family medicine or internal medicine department at Mayo Clinic in 2001 were sent a questionnaire to determine 1) the factors that influenced their choice of physician and 2) their knowledge of the characteristics of both specialties. Forty-six percent of the patients responded. Patients most often cited the doctor's "Approach to patient care" and "Interpersonal skills/communication" as affecting their choice of physician. Results also showed patient knowledge of the difference between family medicine and internal medicine was poor. The authors conclude that patients must be educated about the differences in the training of and care provided by different types of primary care physicians.     

Adverse effects of faculty practice on diagnostic content of residents' outpatient experience

The outpatient experience of two cohorts of family medicine residents was compared. Those who worked at a site with an existing faculty practice had fewer pregnancy-related patient encounters and proportionately more encounters for acute self-limited care compared with residents at a site without a faculty practice (P less than .001). More important, the faculty-associated residents also cared for fewer patients with a variety of chronic diseases and saw them less frequently. These findings suggest that a coexistent faculty practice may have adverse effects on outpatient training in primary care.     

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.     

Clinical experience of medical students with primary care career goals.

Two medical students with primary care career goals, in a medical school based at a university medical center, recorded demographic and medical problem information from their patients. They saw a total of 3,391 problems in 2,265 different patients, resulting in a clinical experience similar to that of students from a medical school not based at a university medical center and residents in two family medicine residency training sites. Almost 62.0 percent of problem contacts were seen outside of the medical center hospital, 66.7 percent on ambulatory patients, and 47.3 percent on non-credit rotations, reflecting the intensity of their personal motivation, the support of faculty with primary care backgrounds, and the flexibility of a clinical curriculum offering 50 percent electives. The study demonstrates that it is possible for students in a university medical center to obtain clinical experience with patient problems of the type encountered in the community.     

Documenting attitude changes towards homeless people: comparing two standardised surveys

CONTEXT: Curricula about the care of homeless patients have been developed to improve stigmatising attitudes towards patients living in poverty. The Attitudes Toward Homelessness Inventory (ATHI) and the Attitudes Towards the Homeless Questionnaire (ATHQ) are both validated instruments developed to assess attitudes towards homeless patients. Although these surveys have similar goals, it is not clear which is superior for documenting attitude changes among doctors in training. METHODS: Seven cohorts of Year 2 and 3 primary care internal medicine residents at an urban public hospital in the USA completed the ATHI and ATHQ in a confidential manner before and after a 2-week rotation on health care for homeless patients (n = 25). RESULTS: Both the ATHI (P < 0.001) and the ATHQ (P = 0.050) documented changes in residents' attitudes. The magnitude of the pre/post change was 0.63 per item for the ATHI and 0.13 per item for the ATHQ. When the ATHI per-item change was standardised to reflect the change that would be expected if there were 5 response choices instead of 6, the per-item change for the ATHI was 4.1-fold greater than for the ATHQ (P = 0.001). Residents improved their responses to 1 of every 8 statements on the ATHQ and 1 of every 2 statements on the ATHI after the course. CONCLUSIONS: Both the ATHI and the ATHQ documented improvement in residents' attitudes after a 2-week homeless medicine curriculum. However, the ATHI was 4 times more responsive to change. These findings suggest that the ATHI is superior for detecting changes in attitudes after an educational intervention.     

Impact of new duty-hour rules on residency training

On the surface, changing the rules related to the number of hours residents work per day and per week sounds like a good idea. Theoretically, residents who work fewer hours would be less tired and provide better patient care. But even small changes in residency training programs have implications for the quality of the educational experience and the cost of training, as well as patient care. This article highlights the challenges that two Minnesota residency programs are facing as they adapt to the new rules around residents' work hours.     

Use of a sports medicine clinic in a family practice residency

The experience of a pilot sports medicine clinic in affiliation with a family practice residency program is reviewed. The use of volunteer orthopedic staffing along with residents working in an acute sports medicine clinic in a community hospital proved to be a valuable addition to the orthopedic exposure during residency training. Seventy-eight patient contacts involving 93 injuries were encountered over a seven-week period. Three injuries required hospitalization for further definitive care. The benefits derived suggest that a similar clinic setup in other residency training programs could enhance the required orthopedic rotation as well as give acute, responsible care to the injured athlete. Educationally the resident's role as the athlete's physician provided a clinical experience valuable to a primary care practice.     

Improving capacity to care for patients with intellectual and developmental disabilities: The value of an experiential learning model for family medicine residents

BackgroundPatients with intellectual and developmental disabilities (IDD) are more likely to experience poor health outcomes and family physicians receive inadequate training to provide appropriate care to this patient group. Little prior research has studied how to effectively train family physicians to care for patients with IDD.ObjectiveThe aim of this pilot study was to assess the value of adding an experiential component to didactic education strategies to improve family medicine resident perceived comfort, skills and knowledge related to caring for patients with IDD.MethodsStructured education programs for residents were implemented at three primary care practices in Ontario, Canada. Two practices received didactic information only (didactic-only group); one received didactic information and an experiential training model including clinical interactions and a written reflection on that experience (didactic plus experiential group). In this separate-sample pre-post design, residents were invited to complete a brief anonymous survey prior to and following the training assessing their perceived comfort, skills and knowledge related to patients with IDD.ResultsAt baseline, there were no significant differences between the two groups of residents. At follow up, the experiential group reported significantly higher levels of comfort, skills, and knowledge compared to baseline for most items assessed, while in the didactic-only group most items showed little or no improvement.ConclusionThis pilot study suggests that providing residents the opportunity to participate in clinical encounters with patients with IDD, as well as a structured process to reflect on such encounters, results in greater benefit than didactic training alone.     

Sensitivity to patient''s psychosocial concerns: Relationships among ratings by primary care and traditional internal medicine house officers and patient self-assessments

This study examined house officers' sensitivity to patients' psychosocial concerns. Primary care house officers, traditionally trained internal medicine house officers, a social worker, and 104 ambulatory care patients independently completed an assessment instrument to indicate the extent to which a set of 20 defined psychosocial issues concerned the patients. We examined the magnitude of difference and extent of correlation in the independent reports of the patient, house officer, and social worker. These analyses were conducted on both the individual psychosocial issues and on sets of concerns derived from an oblique rotation factor analysis of the patients' responses. Primary care trainees' assessments of their patients' concerns correlated more frequently with the independent assessments of the patients and a social worker than did the judgments of the traditionally trained house officers. The factor analysis identified six factors that accounted for 64.4% of the variance in patients' responses. The correlations between the primary care trainees' and patients' assessments were statistically significant on five of these six factors; the correlations between the traditionally trained residents' and patients' assessments were statistically significant on two of the factors. These results provide evidence of the primary care house officer training program's achievement of the goal of enhanced physician awareness of patients' psychosocial concerns. The results also support training efforts aimed at increasing physicians' ability to assess their patients' psychosocial concerns.     

Gatekeeping in primary care: a comparison of internal medicine and family practice

Five hundred twenty new patients were randomly and prospectively assigned to receive their care in the Internal Medicine Clinic or Family Practice Clinic of a large university hospital. The patients were followed by residents in training under the supervision of board-certified internists or family physicians. After a mean length of care of slightly over two years, the charts were reviewed for frequency of visits to primary care providers (internal medicine or family practice), Emergency Room, Acute Care Clinic, and all clinics other than the two primary care clinics. The records were also reviewed for laboratory tests ordered. Frequency of visits to the clinic of primary care, Emergency Room, Acute Care Clinic, and broken appointments were all significantly higher for patients randomized to the Internal Medicine Clinic. In addition, the median total annual cost of laboratory tests for patients followed by internal medicine physicians was significantly higher, largely because of higher laboratory charges generated by the specialist consultants. Over the study period, internal medicine patients had a significantly higher number of visits to all nonprimary care clinics and specifically to the dermatology, obstetrics and gynecology, and general surgery consultant clinics. It can be concluded that in this clinical environment, the practice styles of internal medicine and family practice are different.     

Impact of physician training level on emergency readmission within internal medicine

OBJECTIVES: The research question was whether training level of admitting physicians and referrals from practitioners in primary health care (PHC) are risk factors for emergency readmission within 30 days to internal medicine. METHODS: This report is a prospective multicenter study carried out during 1 month in 1997 in seven departments of internal medicine in the County of Stockholm, Sweden. Two of the units were at university hospitals, three at county hospitals and two in district hospitals. The study area is metropolitan-suburban with 1,762,924 residents. Data were analyzed by multiple logistic regression. RESULTS: A total of 5,131 admissions, thereby 408 unplanned readmissions (8 percent) were registered (69.8 percent of 7348 true inpatient episodes). The risk of emergency readmission increased with patient's age and independently 1.40 times (95 percent confidence interval [CI], 1.13-1.74) when residents decided on hospitalization. Congestive heart failure as primary or comorbid condition was the main reason for unplanned readmission. Referrals from PHC were associated with risk decrease (odds ratio, 0.53; 95 percent CI, 0.38-0.73). CONCLUSION: The causes of unplanned hospital readmissions are mixed. Patient contact with primary health care appears to reduce the recurrence. In addition to the diagnoses of cardiac failure, training level of admitting physicians in emergency departments was an independent risk factor for early readmission. Our conclusion is that it is cost-effective to have all decisions on admission to hospital care confirmed by senior doctors. Inappropriate selection of patients to inpatient care contributes to poor patient outcomes and reduces cost-effectiveness and quality of care.     

Evidence of improved knowledge and skills after an elective rotation in a hospice and palliative care program for internal medicine residents

There is compelling evidence that residents training in primary care need education in palliative care. Evidence for effective curricula is needed. The objective of this study was to test whether a clinical elective improves measures of knowledge and skill. Residents from three categorical training programs in internal medicine were recruited to an elective including clinical experiences in an acute hospital palliative care consultation service, on an acute hospice and palliative care unit, and in-home hospice care. A 25-question pre- and post-test and a videotaped interview with a standardized patient were used to assess communication skills and measure outcomes. Residents demonstrated a 10 percent improvement in knowledge after the four-week elective (p < 0.05). All residents demonstrated basic competency in communication skills at the end of the rotation. These results indicate that clinical rotation shows promise as an educational intervention to improve palliative care knowledge and skills in primary care residents. An important limitation of the study is that it is an elective; further studies with a required rotation and/or a control group are needed to confirm the findings.     

Nurses in resident evaluation. A qualitative study of the participants' perspectives

This study complemented a large psychometric study using nurses to assess medical residents' humanistic behavior. It was designed to identify how nurses and residents defined humanistic qualities and behaviors and what factors affected their views of residents' performance and evaluation. The study also illustrates how qualitative methods were used to complement quantitative psychometric data and thereby yield a more complete assessment of the value of a new performance evaluation form. The results indicated that nurses' definitions of humanistic behavior often differed from residents', tending to reflect a broader perspective on the physician's role and responsibility in patient care. Nurses and residents disagreed about whether nurses were qualified to evaluate residents' humanistic behavior and about what nurses actually observed on the wards. Professional respect was an issue for both nurses and residents. The discussion section identifies some implications for resident training and nurse-resident relationships and supports the value of combining research strategies when evaluating complex human behavior.     

An exploration of patients' trust in physicians in training

Several characteristics associated with patient trust are identified. To determine the level of trust patients from disadvantaged circumstances have in their primary care resident physician, and to determine patient and physician characteristics that predict trust, we administered a survey to randomly selected primary care patients of an academic medical center staffed by internal medicine residents after a visit to their primary care provider. Participants were adults. The group was racially diverse (50% non-white), English-speaking, and from lower socioeconomic groups. The 10-page survey consisted of 7 sections (Physician Trust Scale, Patient Demographics, Patient Health and Well-Being, Patient-Physician Relationship Characteristics, Global Doctor Trust Scale, and Physician Characteristics). The average trust score for primary care providers was 42.70 (standard deviation [SD] 6.20, maximum possible 50). Patient trust was associated with female gender of the participant, higher education level, male physician, and gender concordance between physician and patient, and was inversely related to patient age. Trust in the doctors and nurses at the hospital in which the clinic was located also had a positive association with trust. These patients from lower socioeconomic groups had relatively high levels of trust compared with patients from higher socioeconomic groups discussed in the literature.     

Gaps in quality of diabetes care in internal medicine residency clinics suggest the need for better ambulatory care training

To ensure that medical residents will be prepared to deliver consistently high-quality care, they should be trained in settings that provide such care. Residents in internal medicine, particularly, need to learn good care habits in order to meet the needs of patients with diabetes and other common chronic and high-impact illnesses. To assess the strength of such training, we compared the quality of medical care provided in sixty-seven US internal medicine residency ambulatory clinics with the quality of care provided by 703 practicing general internists. We found significant quality gaps in process, intermediate outcome, and patient-experience measures. These inadequacies in ambulatory training for internal medicine residents must be addressed by policy makers and educators-for example, by accelerating the movement toward new residency curricula that emphasize competency-based training.