Maximizing patient care services to improve funding in a family medicine residency

The authors discuss ways to increase the funding base of a family medicine residency program through the appropriate use of procedures related to patient care and the provisions of service. Following a commitment of cooperation by residents and faculty members, certain principles of a business practice management curriculum were expanded and applied to a residency program. A written procedure manual describing the intricacies of the fee-for-service system was prepared for interns. Mechanisms for the review of patient care productivity and educationally productive incentives were developed. All of these steps were helpful in achieving improvement in the funding base for the residency. Areas for potential expansion in training programs and financial and staffing strategies to increase revenues are discussed. Although administrative decisions regarding fees and collection mechanisms are mentioned, this discussion focuses on educational and patient care activities that also produce revenue.     

Participation of volunteer faculty members in education research projects

Physicians in private practice who are also volunteer clinical faculty members are a recognized resource for teaching and patient care at teaching hospitals. Clinical faculty members have seldom been included in education research despite the frequent complaint from community practitioners that the results from studies at teaching hospitals are not applicable to community practice. The authors report on a study involving volunteer clinical faculty members in a randomized education trial to improve patients' everyday functioning. Seventy-six clinical faculty physicians in office practice of internal medicine participated. At the end of the study the physician participants were asked to complete an evaluation questionnaire concerning the appropriateness of clinical faculty members' participation in such research projects. Ninety-five percent said the experiment was appropriate, and 88 percent would participate again.     

Family medicine research. Status at the end of the first decade

In a national survey of family medicine university units and residencies, 549 MD and 135 PhD faculty pursuing family medicine research were identified. Resources available for research were assessed, as were practice data system characteristics. The practice base nationally of programs pursuing research included 2.6 million patients from 1 million families, making 5.1 million visits per year. Common major impediments to research reported by programs included lack of faculty time (78%), lack of funding for faculty (61%) or staff, equipment and supplies (48%), and lack of research skill (45%) and role models (43%). The annual amount of all research grants received for calendar year 1979 was $3.4 million, of which $2.6 million was from federal government sources. This represented 0.06% of the federal health research effort. Continued development of family medicine research will require increased funding support both for research and research training.     

Two combined residency programs in internal medicine and pediatrics

Combined residency training in internal medicine and pediatrics is becoming a popular postgraduate program among graduating medical students. The number of such programs has increased rapidly but with little interchange of ideas and without the benefit of a national data base. In this paper, the authors review the experience of two combined programs. Initially established because of the desire to provide broad-based training in primary care, the programs now offer a curriculum that prepares residents for primary care or education in the subspecialties. The difficulty for residents of achieving competence in two disciplines is compounded by a lack of faculty role models. The two programs offer special advantages to the residents and the departments involved. The career outcomes of program graduates have varied from primary care or subspecialty practice in one or both disciplines to faculty positions in teaching institutions. Whether the program remains successful will depend on the ability of its graduates to offer special talents to academic and clinical practice settings and on the availability of funding.     

Adult immunization: the medical record design as a facilitator for physician compliance

A three-year prospective chart audit of a family practice residency program was performed to measure physician compliance in following the recommendations of an adult immunization program. Despite curriculum changes, performance self-evaluation, and reminders by faculty members to residents about the need for adult immunization, physician compliance was poor in the second year of the study. It was thought that components of the medical record might be improved to facilitate physician compliance in the adult immunization program. At the beginning of the third year of the audit, tetanus and pneumococcal vaccines were preprinted on the health maintenance inventory (HMI), but influenza was not. The chart design also was changed to put the HMI in a more prominent place. In the third year of the audit, physician compliance with tetanus and pneumococcus immunization improved significantly. The results of the chart review suggest that physician compliance with adult immunization programs can be improved with appropriate chart design.     

Effect of prepaid health plans on a family practice residency

The rapid growth of prepaid health care plans imposes clinical, financial, and educational changes on residency programs. In the study reported here, the authors examined some perceived and actual effects of such plans on a family medicine center associated with a family medicine residency training program. In the study, 37 residents and 19 faculty members completed a 5-point, 16-item survey covering the effect of the prepaid plans used at the center on the program's practice profile, cost-containment efforts, and education activities over a three-year period. Overall, the respondents agreed with the need for cost containment that accompanied participation in the prepaid plan and agreed that prepaid plans increased the number of patient visits and visits by family members. The residents and faculty members agreed that prepaid patients were more demanding and were seen more often for minor or inappropriate problems. Regarding the educational impact of the prepaid plans, the respondents agreed that they improved their clinical decision-making, and no significant concern regarding limitation of laboratory or consultations was noted. Some of the respondents' perceptions were corroborated by findings in the clinic data base that showed increased numbers of patient visits, more visits by members of the same family, and no significant change in outpatient consultation rates.     

The community as preclinical classroom: experience with a first-year clerkship

The required first-year clerkship in family and community medicine at the University of Massachusetts Medical School is a major curricular innovation which has implications for physician education. Students have lived in communities and worked in health service settings with field sponsors, under full-time faculty guidance, in all regions of Massachusetts. This has been one answer to the school's mandate to address the physician maldistribution problem. The goals and objectives and the teaching methods used to implement the program are described. These lessons were drawn from the program experience: community medicine clerkships belong in the first year of the curriculum; full-time medical school faculty working with the field sponsor promotes an optimal learning environment; long-term evaluation remains an important consideration. The first eight years of experience with the clerkship have demonstrated its value, and it should be considered for inclusion in the curriculum of other medical schools.     

Office procedural skills in family medicine

In a study of 131 residents, 34 faculty members, and 236 graduates at nine family practice residency programs in Iowa, 29 office and outpatient procedural skills (for example, repair of lacerations) were identified as representing the ideal core content for family practice residency training, and another 11 procedures (for example, endometrial biopsy) were identified as elective procedures. The faculty members' responses that residents were taught these 40 procedures by direct supervision were much higher than third-year residents' reports of having been supervised while performing them. There was a positive relationship between the percentage of residents who reported having been supervised and the percentage who felt competent to perform the procedures. There was strong agreement among faculty members, residency graduates, and the residents that residents should be evaluated by direct observation of their performance of both core and noncore procedures. Therefore, the view that evaluation by direct observation would be resisted by residents is not supported by this study. As a result of these findings, the authors encourage programs to establish processes for assessing and documenting residents' performances of office and outpatient procedures.     

A measurement process for evaluating clinical teachers in internal medicine.

With input from faculty members and residents in the internal medicine residency training program at McMaster University, Hamilton, Ont., the authors developed a form to evaluate attending physicians in clinical teaching units according to 14 domains of performance. Although brief, the form included all main areas of teacher performance, allowed specification of attending physician behaviour and differentiated areas of strengths and weaknesses between and within attending physicians. The authors describe the new evaluation process and the results for 41 attending physicians.     

不同岗位家庭医生团队成员的激励因素研究

背景　要提高家庭医生团队成员工作的主观能动性,需要建立有效的激励机制,不同激励因素对家庭医生团队成员的影响不同。目的　比较不同岗位家庭医生团队成员激励因素现状、满意度及激励因素偏好,为进一步细化完善家庭医生团队激励机制提供依据。方法　于2019年7-9月在厦门市、杭州市余杭区、上海市长宁区、北京市西城区和房山区共选择27家社区卫生服务中心,采用课题组自行设计的问卷对所有在岗的家庭医生团队人员676人（包括临床医生、护理人员和公共卫生人员）进行普查,调查内容主要包括家庭医生团队人员的个人基本情况和工作环境基本特征、激励机制及激励因素偏好情况。对不同岗位家庭医生团队成员的基本情况及激励因素差异进行分析。结果　共收回有效问卷676份,有效回收率为96.6%。不同岗位家庭医生团队成员的月收入、总收入中家庭医生专项资金占比和签约服务费占比比较,差异有统计学意义（P<0.001）,从事临床医疗工作者高于从事护理和公共卫生工作者（P<0.016 7）。不同岗位家庭医生团队成员对收入与家庭医生工作价值匹配程度的评价比较,差异有统计学意义（P<0.05）;从事公共卫生工作者认为收入与工作价值匹配的比例高于从事护理工作者（P<0.016 7）。不同岗位家庭医生团队成员对福利待遇的满意度比较,差异无统计学意义（P=0.204）。不同岗位的家庭医生团队成员参加阶段性进修培训、相关专业课程培训情况比较,差异有统计学意义（P<0.05）;从事临床医疗工作者参与阶段性进修培训者占比高于从事护理与公共卫生工作者（P<0.016 7）;从事临床医疗工作者过去1年参加相关专业课程培训者占比高于从事护理工作者（P<0.016 7）。不同岗位的家庭医生团队成员过去3年职务提升与职称提升比较,差异无统计学意义（P>0.05）。3种岗位的家庭医生团队成员绝大多数都认为个人收入和福利是最重要的激励因素,这一比例在家庭医生、护士和公共卫生成员中分别是95.6%（387/405）、95.7%（180/188）和98.8%（82/83）;培训机会、社会认可和尊重、职称晋升机会排在第2位、第3位和第4位;但对家庭医生来说单位管理制度是排名第5的激励因素,对护士来说工作量是排名第5的激励因素,对公共卫生人员来说排名第5的则是工作条件。结论　不同岗位家庭医生团队成员的激励机制现状存在较大差异,从事临床医疗工作的家庭医生团队成员收入、福利待遇与培训学习情况优于从事护理和公共卫生工作的人员,且不同家庭医生团队成员对激励因素的偏好有所不同。应当继续优化家庭医生团队成员薪酬结构,提升家庭医生团队的收入及签约服务费,完善经济激励措施;加强基层培训学习力度,提升基层医疗卫生机构服务能力;保障医疗卫生人员权益,提高基层医务人员的社会认可度。     

Teacher training for medical faculty and residents.

Since 1984 the University of British Columbia's School of Medicine has offered teaching improvement project systems (TIPS) workshops on effective teaching techniques; two workshops a year are given for medical faculty members and two a year for residents. The faculty members who conduct the workshops have received training on how to present them. The most powerful learning experience offered by TIPS is the opportunity for participants to present 10-minute teaching segments that are videotaped and later viewed privately by the participants. Eight workshops have been attended by 166 faculty members, and two others have been attended by 42 residents. This project demonstrates faculty development for both the participants and the people who teach the workshops.     

Factors determining patients' satisfaction in a family practice residency teaching center

A primary function of family medicine teaching centers is to provide residents with ongoing experiences with patients and their families. A critical issue in maintaining a stable patient population for such teaching is patient satisfaction. In the study reported here, the authors examined the factors determining patients' satisfaction. A questionnaire was mailed to a representative sample of 10 percent of the patients in a family practice in a family medical center. Seventy-eight percent of the sample responded; these respondents were representative of the sample population. Four variables were identified as significant in determining the patients' satisfaction: whether the patients felt that the time spent with their identified family physician was adequate and that the physician's explanations regarding their health care and the teaching program were clear; whether the patients felt comfortable in expressing their concerns about the teaching program to the permanent staff members; whether the patients had a positive attitude regarding the teaching program; and whether the patients felt that their identified family physician was available to them.     

Family medicine training--the international experience

Family medicine is undergoing dramatic transformation around the world. Its organisation, delivery, and funding are changing in profound ways. While the specifics of primary care reform vary, a common emerging strategy involves establishment of primary health care teams that provide improved access, use electronic records, are networked with other teams, and are paid using blended payment schemes. More family doctors are needed in all countries. New approaches beyond the traditional apprenticeships or residency programs will be required to meet global demand. Training of family doctors must change to prepare tomorrow's family physician for a different practice reality. Curricula are more competency-oriented, rather than time-focused. Today's trainees can anticipate a career that includes periodic reassessment of their knowledge base and competency. This article explores these trends and offers some strategies that have proved effective in various parts of the world for training increased numbers of qualified family doctors.     

Development of residency program guidelines for interaction with the pharmaceutical industry. Education Council, Residency Training Programme in Internal Medicine, Department of Medicine, McMaster University, Hamilton, Ont.

Medical residency programs are likely to face increasing pressure to address their relations with the pharmaceutical industry. Our internal medicine residency program has developed guidelines that were adopted after extensive debate by residents and faculty members. The guidelines are based on the principles that residents and faculty should set the educational agenda and that the residency program should not allow gifts of any sort from industry to residents. Specific policies include obtaining and screening educational materials from the industry before residents are exposed to them, proscribing "drug lunches" and accepting industry sponsorship only when the residency program maintains complete control of the educational event being sponsored. The industry response to the guidelines was split; about half reacted negatively, and half found the guidelines acceptable. Our experience suggests that productive debate about guidelines for the interaction of residency programs with the pharmaceutical industry is possible and desirable and that explicit policies can clarify areas of ambiguity.     

Why are clinical problems difficult? General practitioners' opinions concerning 24 clinical problems.

This study was conducted to describe the difficulties perceived by general practitioners concerning 24 common clinical problems and to compare their perceptions with those of faculty members in family medicine. A random sample of 467 general practitioners and all 182 faculty members in family medicine in Quebec were sent one of four open-ended questionnaires, each of which dealt with six clinical problems; 214 general practitioners and 114 faculty members participated. A total of 5111 difficulties were reported; the number reported by each subject varied from 0 to 13 (mean 2.6 [standard deviation 2.09]) per problem. The problems that generated the most difficulties were depression, confusion in the elderly, chronic back pain, loss of autonomy in the elderly and sexually transmitted disease. The most frequent difficulties were with the patient's noncompliance with treatment, clinical diagnosis, failure of a specific treatment, inadequate health care resources and the physician's own emotional reactions. The difficulties for each problem were the same in the two groups 70% of the time. Physician's perceptions of their difficulties can be useful in the planning of initial training and continuing medical education.     

Faculty members' evaluations of sabbaticals

Seventy medical school faculty members at seven institutions who had taken a sabbatical leave were interviewed about their sabbatical experiences, and 15 who were eligible but had not taken a sabbatical were asked their reasons for abstaining. Nineteen of 35 medical schools solicited also provided information about sabbaticals. The sabbatical experience was viewed very favorably by 80 percent of the participants; and three out of four were judged by the authors of the present paper as having accomplished something substantial, such as writing research papers or books or reorganizing teaching programs, following the sabbaticals. Presabbatical planning was emphasized by the respondents as the key to a satisfying sabbatical. Postsabbatical depression was common but not severe. At the 19 responding schools, sabbaticals were taken by an average of less than one-sixth of the eligible faculty members. Faculty members who had not taken sabbaticals gave a variety of reasons for the modest level of participation. Responses of the faculty members who had taken sabbaticals indicated that most medical school administrations did not capitalize on the opportunity to make the results of sabbaticals of maximum value to their institutions.     

Preparing faculty to teach in a problem-based learning curriculum: the Sherbrooke experience.

Over the last 6 years Sherbrooke Medical School has undertaken a major reform of its undergraduate curriculum. A new student-centred, community-oriented curriculum was implemented in September 1987. Problem-based learning (PBL) is now the main educational method. To adequately prepare teachers for the curriculum a series of faculty development programs in pedagogy were offered: first, a 2-day introductory workshop to initiate teachers into educational principles and their application in the new program; second, a 1-year basic training program in medical pedagogy; third, a 1-day workshop on PBL; and fourth, a comprehensive 3-day training program in PBL tutoring. Over 60% of all full-time teachers attended the introductory program and 80% the tutor training program. The 1-year basic training program was completed by 33% of the faculty members. The implementation of these programs, coupled with a high participation rate, resulted in a more student-centred educational philosophy and a greater interest in medical education. This had a significant impact when the new curriculum was instituted. Lessons learned from the experience are discussed.     

U of T Medical School uses multistep strategy to prevent sexual harassment.

The University of Toronto medical school is using a multistep strategy in an attempt to prevent sexual harassment among students and faculty members. A driving force behind the program is Dr. Miriam Rossi, who was recently appointed associate dean of student affairs. As well, the dean of medicine sent a notice to faculty members explaining that there will be zero tolerance "for any behaviour that can be construed to be sexual harassment."     

The effect of health care reform on academic medicine in Canada. Editorial Committee of the Canadian Institute for Academic Medicine.

Although Canadian health care reform has constrained costs and improved efficiency, it has had a profound and mixed effect on Canadian academic medicine. Teaching hospitals have been reduced in number and size, and in patient programs have shifted to ambulatory and community settings. Specialized care programs are now multi-institutional and multidisciplinary. Furthermore, the influence of regional planning bodies has grown markedly. Although these changes have likely improved clinical service, their impact on the quality of clinical education is uncertain. Within the academic clinical department, recruitment of young faculty has been greatly complicated by constraints on licensing, billing numbers, fee-for-service income and research funding. The departmental practice plan based on university funds and fee-for-service income is being replaced by less favourable funding arrangements. However, emphasis on multidisciplinary programs has rendered these departments more flexible in structure. The future of Canadian academic medicine depends on an effective alliance with government. Academia and government must agree, particularly on human-resource requirements, research objectives and the delivery of clinical and academic programs in regional and community settings. The establishment of focal points for academic health sciences planning within academic health sciences centres and within governments would assist in these developments. Finally, government and the academic health sciences sector must work together to remove the current impediments to the recruitment of highly qualified young faculty.