Restructuring a family practice obstetrics curriculum

Maintaining a high-quality curriculum for family practice residency training in obstetrics has become increasingly difficult. In 1984 the faculty of the University of Vermont Department of Family Practice needed to upgrade its obstetric curriculum in a community where family practice obstetrics was nonexistent. The key steps to a new curriculum included the recruitment of family practice faculty with experience in obstetrics, expanded communication with the Department of Obstetrics and Gynecology, the development of baseline attending privileges in family practice obstetrics, the formation of educational tracks for residents, and the promotion of chart audits. Also important were faculty role modeling, intradepartmental meetings, intensive elective rotations, and community education. This case report of program development in family practice obstetrics may serve as a model to help other residency programs.     

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.     

A Strategy to Increase the Number of Urban Family Practice Resident Physicians Who Enter Rural Practice

Physician geographic maldistribution is a problem in the United States health care system. Innovative strategies are needed to entice resident family physicians training in the larger, more numerous suburban and urban training programs to practice in rural areas upon completing their training. This paper describes a strategy used at St. Elizabeth Medical Center Family Practice Residency Program, Dayton, OH, to encourage rural practice. In the St. Elizabeth plan, the interested family practice resident moonlights in a rural practice provided by the local county hospital. The county medical staff covers the resident physician's practice during the frequent absences. The residency program faculty provide on-site supervision, telephone back-up coverage, and practice consultation. The county hospital provides billing services; the resident physician retains 100 percent of collections. The resident physician gains exposure to the knowledge, skills, and attitudes needed in rural practice. Upon completion of residency training, the physician remains in practice and is not required to pay back any expenses incurred by the hospital. Two resident physicians participate currently; three others have expressed interest in practicing in the community. A similar plan might work in parts of the United States where, like Ohio, training programs and rural communities are not far apart.     

Education as a hidden cost in ambulatory care

Since nearly a quarter of this nation's hospitals' outpatient and emergency rooms engage in medical education, it is of critical importance for administrators to determine the extent to which medical training influences the operational costs and efficiency of patient care for those services in their facilities. A computer simulation model has been developed at a midwest adult medical clinic to study the effects of ambulatory medical training on clinic operations. The model is capable of showing changes in the facility without disrupting the work flow and thus reduces the problems associated with long-term data collection. Various staffing patterns, both with and without medical training, were compared for the operational effects, patient convenience, and costs. The article offers probability distributions based on actual clinic experience. The research identifies and evaluates the trade-offs that must be considered when medical education is incorporated in an ambulatory program. Since both the faculty and students must take time away from direct patient care for consultation, more clinic time is required, causing staff costs to increase and patient care efficiency to decrease. The model demonstrates that when teaching loads increase, the faculty become less available to residents which results in resident inefficiency and longer patient waiting time. These operational consequences demonstrate the basic management problems of the need for balance between the demand for clinical teaching time and the demand for efficient service delivery in a solid ambulatory care/teaching program.     

Preceptor development in residency training through a faculty facilitator

To address the demand for training preceptors, a community hospital-based residency program is using a part-time preceptor in a consultative capacity as a faculty facilitator to model, assess skills, and generally improve the level of teaching. Direct observation of resident-patient interactions and subsequent preceptor critiques are followed by feedback to the preceptor on the cogency and effectiveness of comments made. Goals, objectives, and teaching style are jointly examined by the preceptor and faculty facilitator. Evaluation of videotaped resident-preceptor interactions before and after six months' experience with the faculty facilitator shows significant increases in preceptor skills. Greatest improvement is in comments related to resident's clinical assessments, the resident-patient relationship, and in the quality of the resident-preceptor interaction. Scores by the faculty facilitator are significantly lower but parallel those of an independent, blind evaluator. Preceptor, resident, and administration reactions to the project are all positive. This ongoing program assures the continued upgrading of preceptor skills and provides for faculty attrition. A faculty facilitator providing direct feedback in the clinical setting is a low-cost and viable alternative to workshops and conferences for training effective teachers of family medicine.     

Tennessee: using a statewide data system for family planning

In 1970, the Tennessee state health department established a statewide system for collecting family planning data which are used by service providers and planners to manage the statewide program and evaluate ongoing program efforts. Teach-ins were held explaining the reasons for instituting the system, the potential use for clinic staff, and extensive directions on completing the data forms. The first form is a medical visit record, used principally for admission, medical followup, and annual return visits. The second form is a record for non-medical transactions as recruitment, resupply, or counseling. The forms are to be filled out by clerical, paramedical or nursing staff. Through the system, monthly reports of delinquent patients may be utilized for followup and each county can be ranked according to the proportion of estimated numbers in need of family planning services who have been served. 6 reports are sent to each county monthly, including: 1) a due list of those due to return for services over the next 6 weeks; 2) a missed list of patients who missed their scheduled return for service during the preceeding 2 months; 3) a dropped list of patients 2 or more months overdue; 4) a monthly listing of county rankings by the proportion of local target population currently receiving services; 5) a report on patient activity status by method of contraception; 6) a monthly report on number of visits showing which members of each county's clinic staff are delivering which types of services. A major reason for initiating a centralized record system was to stimulate interest in family planning at the county level, while giving each county a tool to evaluate its own performance and compare its program to other counties. County continuation rates vary from 40.1% to 77.6%. For the state as a whole 54.6% of the 46,950 pill patients were still active 1 year after their initial clinic visit.     

Experiences of a New Migrant Health Clinic

Su Clinica Familiar in Willacy County, Texas established a nurse-midwifery service in 1972 that has expanded to the point of doing the majority of the deliveries in that county. High quality of care of infants and mothers has resulted from a prenatal program which places great emphasis on nutritional counseling and supplementation coupled with careful observance of a pregnant woman's condition, delivery in a clinic facility without the traditional restraints on the mother and family, and a 24-hour post-partum clinic stay followed by two home visits to ensure the health maintenance of mother and infant.     

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.     

Fixing family medicine residency training

The number of US medical students entering family medicine continues to decline. Despite the increased presence of family physicians on medical school faculty and increased exposure to family medicine during training, students still cite lack of respect and excessive knowledge base to master as reasons for not choosing our specialty. Specific changes must be made to family medicine residency training to make it more attractive to students and more compatible with the realities of practice today. These changes include eliminating maternity care as a requirement, lengthening training to 4 years, and reducing the number of residency slots available. These changes will ensure that graduating family physicians will be better prepared for practice, better qualified to obtain privileges in the hospital and clinic, and more respected by their colleagues and the public.     

The AMA Residency Training in Adolescent Preventive Services Project: report of the working group. The American Medical Association.

PURPOSE: To improve resident education in provision of adolescent preventive health care. The American Medical Association (AMA) Residency Training in Adolescent Preventive Services Project Working Group convened to identify specific goals and objectives (G&Os) for pediatric and family medicine resident education in adolescent clinical preventive services and recommend strategies to achieve these G&Os. METHODS: Iterative review process involving members of the working group, nine experienced teaching faculty and 16 resident physicians from family medicine and pediatric training programs, and an advisory board. RESULTS: We achieved consensus on appropriate G&Os for pediatric and family medicine residency education in adolescent clinical preventive services. Faculty and residents expressed concerns about achieving G&Os because of challenges to implementing effective training and evaluation strategies. Suggestions for achieving G&Os included development of an adolescent clinical preventive services curriculum and evaluation program that could be adapted for use in a variety of training program structures. Faculty and residents anticipated the success of a training curriculum would be influenced by: (a) availability of adequate numbers of skilled teaching faculty; (b) availability of time and support for faculty development and teaching efforts; and (c) exposure of residents to adequate numbers of adolescent patients in settings where there are clear expectations for delivery of comprehensive preventive services. CONCLUSIONS: The AMA Residency Training in Adolescent Preventive Services Project Working Group presents G&Os for organizing training experiences in adolescent clinical preventive services in family medicine and pediatric residency training programs and recommends strategies to achieve these G&Os.     

An accelerated rural training program

BACKGROUND: Several authors have pointed out the need for enhanced training for those residents contemplating rural practices. Most students and policy makers are reluctant to commit to primary care training beyond the required 3 years. METHODS: The University of Nebraska Medical Center received approval for an accelerated family practice training program in 1993, and developed a 4-year program that requires a 1-year rural procedures fellowship and a commitment to practice in rural Nebraska. RESULTS: The Nebraska accelerated rural training program has recruited 10 classes to this program and has placed more than 50% of the graduates in communities with a population of less than 8,000. CONCLUSION: The requirements of this program are unique. Special consideration must address the issues of recruitment of students, integration into the basic program, licensure issues, determination of fellowship training needs, and faculty recruitment.     

Introduction of handheld computing to a family practice residency program

BACKGROUND: Handheld computers are valuable practice tools. It is important for residency programs to introduce their trainees and faculty to this technology. This article describes a formal strategy to introduce handheld computing to a family practice residency program. METHODS: Objectives were selected for the handheld computer training program that reflected skills physicians would find useful in practice. TRGpro handheld computers preloaded with a suite of medical reference programs, a medical calculator, and a database program were supplied to participants. Training consisted of four 1-hour modules each with a written evaluation quiz. Participants completed a self-assessment questionnaire after the program to determine their ability to meet each objective. RESULTS: Sixty of the 62 participants successfully completed the training program. The mean composite score on quizzes was 36 of 40 (90%), with no significant differences by level of residency training. The mean self-ratings of participants across all objectives was 3.31 of 4.00. Third-year residents had higher mean self-ratings than others (mean of group, 3.62). Participants were very comfortable with practical skills, such as using drug reference software, and less comfortable with theory, such as knowing the different types of handheld computers available. CONCLUSION: Structured training is a successful strategy for introducing handheld computing to a residency program.     

Teaching physicians to teach: a three-year report.

To meet the needs for an expanded preceptor faculty, the Department of Family Medicine at the College of Medicine and Dentistry of New Jersey-Rutgers Medical School has for three years conducted yearly training programs designed to prepare practicing family physicians for the teaching role. Thirty-six physicians have completed the program, which consists of four group seminars and three individual learning site visits spent in the office of an experienced preceptor while a fourth year student is present. Many lessons were learned in the course of these yearly programs which may be useful to others who plan to undertake similar faculty development activities. Therefore, detailed, practical, experiential information is presented regarding recruitment, orientation, the educational program of seminars and individual learning experiences, evaluation, and required resources. Some problems proved to be particularly difficult, such as the uneven quality of the individual learning visits and the attrition of some participants from the program. Feedback from participating physicians has been extremely positive.     

Editorial: New manpower for family planning services.

In some isolated family planning services innovative uses of new professional manpower are being demonstrated. With specialized training, the paramedical personnel are performing full gynecological screening examinations under the supervision of physicians, serving as clinic administrators, and providing counseling and educative services. Currently not enough funds are being allocated to manpower development. In 1973 only 3% of federal funds for family planning services were earmarked for this endeavor. There also is an unwillingness of a large percentage of medical and health professionals to accept the potential roles of the new professionals as well as to come to grips with the concept of "consumer participation". This consumer involvement is necessary in developing a system that is responsive to the patient's needs. Training periods vary for the new professionals from a few weeks to 3 years to prepare Physicians' Assistants. In a 20 week course individuals have been trained to recognize and differentiate normal and abnormal breast and pelvic findings and to provide family planning and cancer screening services including full pelvic exams and insertion of the IUD. Over 100 new professionals who function as in-hospital family planning counselors and community education technicians in a New York City program were trained through the laboratory method approach. The key to the performance of the new professionals in the clinic is proper supervision and good communication between them and the traditionally trained professionals. Some of the dead-end restrictions which characterize so many of the new positions can be removed if efforts are made within each program to provide in-service training or released time for employees to attend seminars, workshops, of courses at suitable institutions to foster growth and mobility.     

Resource requirements for teaching continuity in primary care: contrasts between a graduate and an undergraduate program

Two similar primary care training programs for family practice residents and for medical students are compared to find differences and similarities in costs and the use of certain nonmonetary resources. Both programs emphasize long-term continuity, and trainees in both programs average two half-days per week at ambulatory care practice sites. Comparisons of the resource requirements of teaching high-continuity primary care curriculum segments between graduate and undergraduate programs will help determine where scarce medical teaching resources can be most beneficially used. It is hypothesized that there would be lower faculty costs, higher auxiliary staff and space requirements, and larger patient panel requirements for the residency program than for the undergraduate program. Extent of these differences could not be predicted. In the residency program, faculty costs were one quarter of total expenses and in the undergraduate program they were half of the program expenses. The residency recouped 81 percent of expenses from practice revenues while the undergraduate program recouped only 59 percent. The residency program averaged 814 visits per trainee during one year; the undergraduate program had only 268 visits per student.     

Establishing a dental practice in a rural, low-income county health department.

Historically, county health departments have not been responsible for providing dental care to needy citizens. However, as the need for dental care among indigent and low-income citizens has grown health departments are being called on to provide these necessary services. This article describes one local board of health's effort to establish a dental program within a large rural county. The board of health directed the local county health department to purchase and operate a mobile dental clinic, build a permanent dental facility, recruit a dental staff, and most important, provide the financial resources to pay for the program.     

Teaching colposcopy and androscopy in family practice residencies

Addressing the widespread human papillomavirus and genital epithelial dysplasia epidemic requires mastery of colposcopy, androscopy, and cryotherapy. Implementing a family medicine residency training program for these skills requires identifying a faculty facilitator to consider the issues of time, cost, caseload, reimbursement, specialist support, personal training, and office impact related to this training. Experience with teaching these skills in a community-based family practice residency indicates that startup costs range from $10,000 to $20,000. Residents will initially require from 30 to 60 minutes to provide a complete examination. All procedures require precepting by trained faculty and adherence to established protocol. The most frequent indications for these procedures include evaluating the abnormal Papanicolaou smear, visible cervical abnormalities, or evidence of clinical papillomavirus infection in either sex. Experience suggests that over 90% of cervical dysplasia can be managed entirely in the residency outpatient setting. These procedures have become the most common outpatient procedures performed, surpassing all others combined. Referrals to the residency for these procedures are readily available. Strategies for developing curriculum, literature review, learning materials, and training workshops are presented. Colposcopy, androscopy, and cryotherapy are appropriate additions to the training curriculum of family practice residencies.     

Medicine and management: a combined educational program

Rapidly evolving characteristics of our health care system are creating new and expanding opportunities for physician managers. Formal graduate degree training in management has become desirable to prepare the physician for these new professional responsibilities. The Schools of Medicine and Management at Northwestern University instituted a formal combined degree program eight years ago. Directed by a physician holding faculty appointments in both schools, the program offers an integrated five year curriculum. During the past eight years, 16 students have matriculated in the program without attrition. Eleven students have completed both degrees on schedule. The results of a comprehensive telephone survey of all U.S. and Canadian medical schools concerning dual degree programs are presented. The advantages and disadvantages of pursuing management training at various stages of a physician's career are discussed.     

Going global: considerations for introducing global health into family medicine training programs

Medical students and residents have shown increasing interest in international health experiences. Before attempting to establish a global health training program in a family medicine residency, program faculty must consider the goals of the international program, whether there are champions to support the program, the resources available, and the specific type of program that best fits with the residency. The program itself should include didactics, peer education, experiential learning in international and domestic settings, and methods for preparing learners and evaluating program outcomes. Several hurdles can be anticipated in developing global health programs, including finances, meeting curricular and supervision requirements, and issues related to employment law, liability, and sustainability.