Family medicine residency training--three or four years?

Opinions about a four-year family practice residency were elicited from a nationally representative sample of three groups of family physicians. Questionnaires were mailed to a random sample of 308 residency graduates aged 30 to 35 years, all 383 residency directors, and a random sample of 319 third-year residents. Two mailings produced an 82 percent response rate. A four-year residency was favored by 32 percent of recent graduates, 20 percent of program directors, and 34 percent of third-year residents. Over 60 percent of residents and recent graduates would have entered a family practice program had the residency been of four years' duration. Perceived barriers to a four-year residency included lack of resources, loss of appeal, and the additional time commitment. Respondents were most willing to complete a fourth year of residency to receive additional training in orthopedics, obstetrics, gynecology, and pediatrics. Many respondents believed that the additional year would be helpful in obtaining hospital privileges in obstetrics and in coronary care and intensive care units. This study provides information useful in discussions regarding extending residency training.     

Moonlighting policy and practice in family practice residencies

Moonlighting by residents is a controversial, but little-studied topic. A survey on moonlighting policy and practice was sent to all family practice residency program directors, and an 87 percent response rate obtained. Moonlighting is permitted by 97 percent of nonmilitary programs and is generally thought of by program directors as a positive educational experience. It is practiced by over two thirds of the second- and third-year residents in programs that monitor moonlighting. These residents spend an average of 28 hours each month moonlighting. The most commonly used moonlighting sites are hospital emergency rooms, followed by coverage for private practice physicians. Seventy percent of programs require approval for extracurricular work activity. Only 23 percent of residencies limit moonlighting for all residents, but 47 percent have had occasion to deny moonlighting privileges to individual residents.     

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.     

Hospital privileges for family physicians at university hospitals

Of the more than 350 family practice residency programs in the United States, 72 are affiliated with a medical school. Seventy-eight percent of these university programs hospitalize all or some of their patients at a university hospital. These hospitals grant various privileges to family physicians with the following frequencies: general medicine (94 percent), adult intensive care (50 percent), coronary care (65 percent), general pediatrics (81 percent), pediatric intensive care (29 percent), normal newborn nursery (79 percent), intensive care nursery (12 percent), routine obstetrics (77 percent), and high-risk obstetrics (31 percent). Sixteen (22 percent) of the university-based programs do not use a university hospital at all, either because the university hospital is too far away or because there is no university hospital. Only one program does not use the university hospital because of difficulty in obtaining privileges. Family physicians are unable to obtain various hospital privileges because of political reasons at the following percentages of university hospitals: general medicine (2 percent), adult intensive care (33 percent), coronary care (40 percent), general pediatrics (8 percent), pediatric intensive care (31 percent), newborn nursery (8 percent), intensive care nursery (29 percent), routine obstetrics (13 percent), and high-risk obstetrics (17 percent).     

Who teaches residents about the prevention and treatment of substance use disorders? A national survey.

BACKGROUND: Studies indicate that physicians are poorly prepared to identify and treat tobacco, alcohol, and drug use disorders. Several faculty development programs have been created to increase the number of residency teaching faculty with expertise in this area. There is limited information, however, on those who currently teach residents about these problems and whether there is a need for additional faculty development programs. METHODS: We conducted a 2-stage national survey of faculty who teach residents about substance use problems. First, residency directors from 7 specialties (family medicine, psychiatry, internal medicine, pediatrics, obstetrics and gynecology, emergency medicine, and osteopathy) responded to a mailed questionnaire asking them to identify faculty who teach residents about substance use disorders. Second, those identified were contacted and asked to participate in a telephone interview. RESULTS: Of 1293 faculty identified by the residency directors, 769 participated in a research interview. Most of these teachers were full-time physician faculty, men, white, and based in departments of family medicine or psychiatry. Teaching was primarily conducted in hospitals, general outpatient clinics, and classrooms rather than alcohol and drug treatment programs. Less than 10% of the faculty performed clinical work in alcohol and drug treatment programs, and only 19% were certified addiction specialists. The respondents reported a definite need for additional development programs for themselves and other residency teaching faculty. CONCLUSIONS: We suggest a modest increase in the number of faculty who teach residents about substance abuse disorders, and the creation of additional faculty development programs.     

Career choices of general preventive medicine residency graduates: 1981-1986

To identify career choices made by recent graduates of general preventive medicine residency programs, all funded residency programs in general preventive medicine (excluding federal and military programs) were surveyed. Eighty-two percent of programs responded and reported on the career choices of 241 graduates who graduated from 1981 to 1986. In order of preference, the categories of career choice were: program activities (36.5%), teaching (19.1%), clinical services (17.0%), and research (6.2%). About one-fifth (21.2%) chose other activities. The number of graduates more than doubled between the periods 1981-1983 and 1984-1986. There was a threefold increase in the percentage of graduates involved primarily in research; however, there was a 33% decrease in the percentage of graduates who became professional academicians.     

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.     

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.     

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.     

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.     

An enhanced obstetrics track for a family practice residency program: results from the first 6 years

BACKGROUND: Advanced training in obstetrics for family physicians occurs through a variety of methods. The program described has developed an obstetrics track for family practice residents. METHODS: Five residents have completed the 4-year residency program with enhanced obstetric training developed, and the results, in terms of procedural experience and examination scores, have been reviewed. RESULTS: These 5 family physicians performed a similar number of obstetric procedures compared with their Obstetrics and Gynecology resident counterparts, and they performed as well as their family medicine resident counterparts on national in-service examinations. CONCLUSIONS: A 4-year enhanced obstetrics track is an effective means of improving the training of family medicine residents in obstetric procedures while maintaining the other fundamental training and residency review committee requirements for family medicine residents.     

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.     

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.     

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.     

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.     

Current Status of Nutrition Training in Graduate Medical Education From a Survey of Residency Program Directors

Introduction: Nutrition leaders surmised graduate medical nutrition education was not well addressed because most medical and surgical specialties have insufficient resources to teach current nutrition practice. A needs assessment survey was constructed to determine resources and commitment for nutrition education from U.S. graduate medical educators to address this problem. Methods: An online survey of 36 questions was sent to 495 Accreditation Council for Graduate Medical Education (ACGME) Program Directors in anesthesia, family medicine, internal medicine, pediatrics, obstetrics/gynecology, and general surgery. Demographics, resources, and open‐ended questions were included. There was a 14% response rate (72 programs), consistent with similar studies on the topic. Results: Most (80%) of the program directors responding were from primary care programs, the rest surgical (17%) or anesthesia (3%). Program directors themselves lacked knowledge of nutrition. While some form of nutrition education was provided at 78% of programs, only 26% had a formal curriculum and physicians served as faculty at only 53%. Sixteen programs had no identifiable expert in nutrition and 10 programs stated that no nutrition training was provided. Training was variable, ranging from an hour of lecture to a month‐long rotation. Seventy‐seven percent of program directors stated that the required educational goals in nutrition were not met. The majority felt an advanced course in clinical nutrition should be required of residents now or in the future. Conclusions: Nutrition education in current graduate medical education is poor. Most programs lack the expertise or time commitment to teach a formal course but recognize the need to meet educational requirements. A broad‐based, diverse universal program is needed for training in nutrition during residency.     

Pregnancy during residency]

The number of female residents in the Netherlands has steadily increased in recent years. Due to the increased time on waiting lists to enter residency programmes and to the increased duration of training, female residents will be older during their residencies. This will probably result in an increased number of pregnancies during residencies. A questionnaire regarding pregnancy during residency was sent to 191 residents in two university hospitals in the Netherlands. The response rate was 74.3%. Fifty percent of the male and only 19% of the female residents had children. No negative effects of a pregnancy on their training were experienced or anticipated by the residents. However, a negative effect on the functioning of the department was expected. No formal provisions, like replacements were available and many solutions to replace pregnant colleagues depended on the flexibility of the colleagues. The wish to have children was high and equally distributed among male and female residents, 92% and 96%, resp. Given the difficulty to seek a permanent position and to have children after residency, the choice of many female residents will be to have their children during residency. This increase in number of pregnancies requires anticipation of the residency programme directors. They should take the lead in proposing adequate regulations.     

The pediatric residency training on tobacco project: four-year resident outcome findings

OBJECTIVE: To evaluate the efficacy of a special program for training pediatric residents to address tobacco. METHODS: In a study conducted at the New Jersey Medical School, sixteen pediatric residency training programs in the New York/New Jersey metropolitan area were assigned randomly to either special or standard training conditions. All of the residents were invited to take part in the training. Only second- and third-year residents participated in data collection activities (baseline and follow-up tobacco surveys and objective structured clinical examinations [OSCEs]). Baseline data were collected in the spring of 2001, and follow-up data were collected annually through the spring of 2005. Special training consisted of a hybrid website/CD-ROM training program on tobacco, a seminar series, companion intervention material, and clinic mobilization. Standard training residents participated in the seminar series and utilized standard educational and self-help material. RESULTS: The percent of residents in special training, but not of those in standard training, who provided assistance for modifying environmental tobacco smoke, preventing use, and helping patients and parents stop smoking increased significantly from baseline to year 4 of training, as did the percent who felt prepared to address tobacco. Performance on the OSCEs was consistent with survey outcomes as special training residents revealed mastery of key interviewing and intervention skills. CONCLUSION: The special training program, with Solutions for Smoking as its centerpiece, was found to be effective for training pediatric residents to address tobacco, and it may serve as a model for pediatric residency training programs. Ways of improving the program are discussed.     

Preparing physicians for careers in primary care internal medicine: 17 years of residency experience.

The objective of this survey was to demonstrate whether a primary care track internal medicine residency program emphasizing community-based health care of the urban sick poor trains physicians who will continue to practice in general internal medicine or similar fields. Thirty-five primary care residents (100% of graduates) who trained from 1976 through 1993 in the Adult Primary Care Track of the Internal Medicine Residency Program at St. Vincent''s Hospital, New York were used as participants.     

Abortion training in U.S. obstetrics and gynecology residency programs

The majority (72 percent) of U.S. residency programs in obstetrics and gynecology include first-trimester abortion techniques in their training. Programs affiliated with public hospitals or with private non-Catholic institutions are the most likely to provide such training, while Catholic-affiliated training programs and those at military hospitals are the least likely to do so. Approximately 23 percent of institutions include abortion training as a routine part of residency, and 50 percent offer it as optional training. The 28 percent of residency programs that offer no abortion training represents an almost fourfold increase since 1976. Although more of the large programs affiliated with public hospitals now include such training as a routine part of their residency programs, fewer of the private non-Catholic programs--where the largest proportion of residents are trained--do so. Consequently, the number of residents exposed to abortion training may have declined slightly over the past decade. Little difference exists between the proportion of programs that offer training in first-trimester techniques and the proportion that train in second-trimester techniques. Nine percent of programs report that all residents participate in first-trimester abortion training, and another 56 percent report that at least half of their residents do so. The participation rate is linked to the expectations of the program: Approximately 88 percent of programs that routinely incorporate abortion techniques in their training report that from one-half to all their residents participate, compared with about 55 percent of programs that offer the training as an option. Approximately 82 percent of programs teach abortion techniques up to at least 20 weeks' gestation.(ABSTRACT TRUNCATED AT 250 WORDS)