Reorganizing a family practice center: strategy to save a residency program at a financially troubled hospital

The family health center of a family practice training program was eliminated from the county hospital budget following funding cuts, forcing the program faculty to create an independent nonprofit community clinic in which to train residents and provide care to established patients. A county audit of the new clinic after 2 years' operation showed substantial savings, particularly for administrative overhead. This report presents data showing the cost advantages to a small private clinic with faculty management compared with costs in a hospital-managed outpatient clinic; the savings were sufficient to assure continuation of the training program. Increased flexibility under faculty management provided a more realistic teaching environment and new research opportunities.     

Continuity of care in family practice. Part 4: implementing continuity in a family practice residency program.

Although continuity of care is an important goal of family practice residency programs, there are many factors which inevitably prevent its full achievement by individual residents in any program. Each resident is frequently faced with conflicting responsibilities involving the Family Practice Center, inpatient clinical services, and other parts of the residency training program. This paper explores this dilemma and suggests a variety of positive approaches to resolve the issue. All family practice residents must necessarily be intimately involved in providing continuity of patient care and develop the requisite skills and attitudes. However, full continuity of care must ultimately be provided on a program and group level, not exclusively by the individual resident.     

Effect of a nationwide program of educational outreach visits to improve the processes of care for patients with type 2 diabetes

OBJECTIVES: To improve processes of ambulatory care for patients with type 2 diabetes in a nationwide program. METHODS: Interrupted time-series analysis with audits of practice. To implement selected recommendations of national guidelines, educational outreach visits (office visits or phone discussions) were offered to all French physicians who diagnosed one case of type 2 diabetes during a six-month intervention period. Outcome measures were the number of HBA1c measurements recorded monthly in the medical insurance computer database and the proportion of diabetic patients for whom one test had been reimbursed during the previous six months (HBA1c, fasting blood glucose) or previous twelve months (serum cholesterol, serum creatinine, urine microalbumin, electrocardiogram, ophthalmologic examination). RESULTS: A total of 15,522 office visits and 9,062 telephone discussions were performed among 22,940 physicians. The increase in the monthly proportion of the number of HBA1c tests to the total number of laboratory tests was higher during the intervention period than during the preintervention (p value < .0001) and postintervention periods (p value < .001). Between the first audit (n = 651,574) and the third audit (n = 911,871), HBA1c measurements increased from 41.2% to 60.5% and blood glucose measurements performed alone decreased from 38.8% to 18.7%. Urine microalbumin measurements increased from 10.6% before to 15.3% after intervention. Only a slight increase was observed for other tests. CONCLUSIONS: Physician to physician outreach visits can be an effective way to improve the processes of care for diabetes and to routinize nationwide use of practice guidelines.     

Exposure to a rural population in a rural residency training program

Previous reports of rural training programs conducted by medical schools have not examined the relationship between the population residing in an area and the population receiving medical services through the clinical training program. In the present study rural household survey data were compared with patient encounter data from a rural ambulatory clinic engaged in training Family Practice residents from the Texas Tech University School of Medicine. Clinic patients were found to resemble the rural population subgroup that visits a physician at least once a year. Wide variations in individual clinical experiences were observed when health problems and conditions encountered by residents were compared with problems encountered in the clinic as a whole. In light of current national efforts to increase medical care access in unserved and underserved populations, the demographic findings raise questions concerning appropriate patient exposure goals in clinical training programs.Dr. Kennedy is with the Texas Tech University Health Sciences Centers, School of Medicine, P.O. Box 4569, Lubbock, Texas 79430. The author is indebted to Angela J. Shepherd for assistance with data processing and statistical analysis and to Dr. Anthony B. Way for comments on an earlier draft of this paper.     

Health beliefs of hypertensive patients in a family medicine residency program.

This paper presents the results of a survey of the hypertensive patient population in a university family medicine practice to determine health beliefs, patient perceptions of the severity of their condition, stated levels of compliance to drug regimens, frequency of drug side effects, and frequency of physician discussions of drug side effects and diet. Health beliefs were then associated with diastolic hypertension and increase in medication dosage over a four-month period. Results of the survey sharpen the focus of patient education efforts by the family physician on specific attitudes, beliefs, and treatment issues which are most appropriate for the hypertensive patient. The physician may improve his/her management of hypertensive patients by: (1) anticipating prevalent myths and misconceptions which patients have concerning hypertension; (2) alleviating patient anxiety by stressing that control of blood pressure decreases the likelihood of complications; (3) effectively communicating to each patient the current status of his/her condition at each visit; and (4) initiating discussion of side effects through direct questioning for those effects most frequently seen.     

Outreach visits to improve dementia care in general practice: a qualitative study.

BACKGROUND: Outreach visits reflect newer developments in adult learning theory, where the learner is actively involved in the session. Previous studies have indicated a positive effect of outreach visits on GPs' behaviour. However, the empirical role of the facilitator in the visits is poorly described. OBJECTIVE: To explore general practitioners' perception of the outcome of a facilitator programme about dementia, in relation to central aspects of the facilitator's communicative role during the visits. METHOD: Observational studies, and focus group discussions with participating general practitioners (3 groups, 19 participants) as well as with facilitators (4 participants) in Vejle County, Denmark. RESULTS: Facilitators drew both on a 'factual' knowledge of dementia and a more 'experience-based' knowledge when conveying programme messages. They described themselves as 'carriers of experience'. All general practitioners described an outcome of the programme, and all wished to receive a future visit by a facilitator on new topics. The outcome was described not as ground-breaking medical news, but as practical effects in terms of knowledge of dementia, motivation for working with dementia, structured assessment and management of dementia and critical reflection of established practices regarding dementia. Some general practitioners remained critical as to whether this outcome justified the resources used in the programme. The experience-based dialogue was described as central to the outcome as it linked factual knowledge to clinical practice. CONCLUSION: This study confirms that outreach visits contribute to the integration of factual knowledge in clinical practice, but it also underscores the importance of addressing tacit communicative practices during facilitator visits and their implications for the outcome of the programme.     

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.     

Evaluating an end-of-life curriculum in a medical residency program

The ability to meet patient needs at the end of life is important. Boston University Residency Program in Medicine initiated a 1-week-long end-of-life curriculum that included a hospice care orientation, core articles, and home hospice visits. Evaluated was the impact of the rotation on participant knowledge and attitude. Knowledge was assessed by pretest and posttest questionnaires and compared with more senior resident controls, na?ve to the curriculum. Attitudes toward issues relating to end-of-life care and subjective change in knowledge were assessed comparing subjects' retrospective preintervention and postintervention responses included in the postintervention questionnaire. Forty-five second-year participants completed both questionnaires. Participants demonstrated significant improvements in attitude and self-assessed knowledge of end-of-life care in 23 of 24 Likert-type scale questions. The end-of-life curriculum led to significant improvements in participant knowledge and attitudes about the conceptual and practical aspects of end-of-life care. The structure of the rotation should be reproducible in many locales.