Pregnancy during residency: a literature review.

PURPOSE: It is estimated that by 2010 30% of U.S. physicians will be women. Pregnancy during residency can and does happen in all programs, and continues to provide problems for many. The author reviews the issues surrounding pregnancy during residency by evaluating published commentaries and research reports. METHOD: A literature search was conducted using Medline (January 1984-October 2001). Published articles were categorized as research or commentary. Research reports were sorted by content and summarized under three headings: mother and infant health, sources of stress and support for the pregnant resident, and reactions of colleagues to the pregnant resident. RESULTS: A total of 27 research reports were located; two additional reports published before 1984 were added because they complemented included studies. The majority of the studies in this review used retrospective self-report questionnaires, mostly completed by female residents and physicians. All reports suggested an increased risk of complications, especially adverse late-pregnancy events, for pregnant physicians. Pregnant residents found the physical demands of residency and lack of support from fellow residents and their departments most stressful. Anger and resentment toward the pregnant resident were common among not-pregnant residents, feelings particularly associated with expectations of increased workload. Individual maternity/parental leave policies were inconsistent. Policy development is discussed. CONCLUSIONS: The studies in this review supported planning for residents' pregnancies, and the author advocates clear maternity/parental leave policies. The author comments on the use of existing data to make common sense changes and on the need for further studies to help clarify the issues and evaluate program changes.     

Internal medicine-pediatrics residency training: current program trends and outcomes.

PURPOSE: Combined internal medicine-pediatrics (med-peds) residency programs have existed since 1967. Due to the rapid growth in the number and size of programs during the 1990s, most current med-peds physicians completed their residency in the last ten years, making older studies of med-peds programs obsolete. The authors sought to determine completion rates of med-peds residency programs and describe the initial career plans for five cohorts of graduating residents from combined med-peds training programs. METHOD: Program directors of all U.S. med-peds residency programs were asked to complete a Web-based survey and base their responses on the records of cohorts of residents completing their programs from 1998 through 2002. To allow sufficient time to complete both the American Board of Pediatrics (ABP) and American Board of Internal Medicine (ABIM) certification examinations, certification status was requested only for the cohort completing training in 1998. RESULTS: Responses were obtained from 92% (83/90) of the programs, reflecting 1,595 residents entering med-peds programs. Of these residents, 91% graduated from a med-peds program. Among the graduates, 82% were seeing both adults and children, 22% went on to subspecialty residencies, 21% began practice in rural or underserved areas, and 25% entered an academic position. ABIM and ABP pass rates for the 1998 cohort were 97% and 96%, respectively. Overall, 79% of the 1998 graduates are board certified in both specialties. CONCLUSIONS: Compared with previous studies, a greater proportion of residents who recently entered med-peds programs completed their dual training, and a larger percentage of graduates are seeing both adults and children. The proportion of residents entering subspecialty residencies has increased significantly, but the proportion of graduates in academic careers has remained stable.     

The roles of nature and nurture in the recruitment and retention of primary care physicians in rural areas: a review of the literature.

PURPOSE: A systematic review of factors associated with recruitment and retention of primary care physicians in rural areas. METHOD: Using PubMed and Medline databases, 21 quantitative articles analyzing recruitment and retention of primary care physicians in rural areas from 1990 to 2000 were found. To assess the methodologic strengths of these articles, a formal evaluation was conducted based on study design, study population, response rate, years studied, data source, and statistical methods (total possible score = 60 points). Studies were grouped by whether the factors assessed were related to pre-medical school, medical school, or residency. RESULTS: A total of six studies (score range: 30-52) analyzed pre-medical school factors, 15 (score range: 30-52) considered medical school factors, and six (score range: 20-52) analyzed residency factors related to rural recruitment and retention. Pre-medical school factors such as rural upbringing and specialty preference were most strongly correlated with recruitment of physicians to rural areas. Training factors such as commitment to rural curricula and rotations, particularly during residency, were most strongly correlated with retention in rural areas. CONCLUSIONS: Although important gaps exist, scientific studies available to health educators and policymakers show there are predictable factors that influence recruitment and retention in rural areas. Policies for staffing rural areas with primary care physicians should be aimed at both selecting the right students and giving them during their formal training the curriculum and the experiences that are needed to succeed in primary care in rural settings.     

The integrative family medicine program: an innovation in residency education.

The Integrative Family Medicine (IFM) Program is a four-year combined family medicine residency program and integrative medicine fellowship. It was created in 2003 to address the needs of four constituencies: patients who desire care from well trained integrative physicians, physicians who seek such training, the health care system which lacks a conventional integrative medicine training route, and educational leaders in family medicine who are seeking new strategies to reverse the declining interest in family medicine amongst U.S. graduates. The program was designed jointly by the University of Arizona Program in Integrative Medicine (PIM) and family medicine residency programs at Beth Israel/Albert Einstein College of Medicine (AECOM), Maine Medical Center, Middlesex Hospital, Oregon Health & Science University, and the Universities of Arizona and Wisconsin. One or two residents from each of these institutions may apply, and when selected, commit to extending their training by a fourth year. They complete their family medicine residencies at their home sites, enroll in the distributed learning associate fellowship at PIM, and are mentored by local faculty members who have training in integrative medicine. To date three classes totaling twenty residents have entered the program. Evaluation is performed jointly: PIM evaluates the residents during residential weeks and through online modules and residency faculty members perform direct observation of care and review treatment plans. Preliminary data suggest that the program enhances interest amongst graduating medical students in family medicine training. The Accreditation Council of Graduate Medical Education Family Medicine residency review committee has awarded the pilot experimental status.     

Practice locations of Texas family practice residency graduates, 1979-1987

The location of a physician's residency training is known to be a factor in selection of a practice location. In this paper, the authors analyze the practice locations of 689 family physicians who graduated from residency programs in Texas between 1979 and 1987 and who were practicing in Texas in 1988. One-third of these graduates were practicing in cities the same size as their residency program city. More than half were in counties located within 60 miles of the residency city. Both of these trends can be explained to a large degree by the fact that a high percentage of graduates remained in their residency city to practice. When these nonmobile graduates are removed from the sample, the findings show no correlation between the size of the residency city and the size of the practice city. More than two-thirds of those graduates who left their residency city were in counties beyond a 60-mile radius. Almost two-thirds were practicing in communities of less than 25,000 population. The authors conclude that state support for family practice residency training has been effective in distributing family physicians in a manner that addresses the needs of the state of Texas as a whole.     

Effects of the reduction of surgical residents’ work hours and implications for surgical residency programs: a narrative review

Background

The widespread implementation of resident work hour restrictions has led to significant alterations in surgical training and the postgraduate educational experience. We evaluated the experience of surgical residency programs as reflected in the literature from 2008 onward in order to summarize current challenges and identify key areas in need of further research.

Methods

We searched MEDLINE and EMBASE for English-language articles published from January 2008 to December 2011 related to work hour restrictions in surgical residency programs, including those pertaining to personal well-being, education and training, patient care, and faculty experiences.

Results

We retrieved 240 unique abstracts and included 24 studies in the current review. Of the 10 studies examining effects on operating room experience, 4 reported negative or mixed outcomes and 6 reported neutral outcomes, although non-compliance was demonstrated in 2 of these studies. Effects on surgical faculty perceptions were consistently reported as negative, while the effect on patient outcomes and professionalism were found to be neutral and unchanged.

Conclusions

Further studies are needed to characterize operative experience at varying levels of training, particularly in the context of strict adherence to new work hours. Research that examines the effect of the work hour limitations on professionalism and non-operative educational activities, such as reading and simulation-based training, as well as sign-over practices, would also be of benefit.

     

A cross-cultural pediatric residency program merger.

Academic health centers, health systems, and, to a lesser degree, medical schools and residency programs have merged, consolidated, or formed strategic alliances. There are few published reports of residency program mergers, and only one involving a merger between a historically black college and university (HBCU) and a predominantly white institution.This case study describes a merger between two dissimilar urban pediatric residency programs. The Howard University Hospital (HUH) pediatric residency program is affiliated with a HBCU, and the Children's National Medical Center (CNMC) pediatric residency program, is affiliated with a leading children's hospital which had relatively few underrepresented minority physicians or residents. The pediatric residency program merger between HUH and CNMC occurred in 2003 and presented organizational, cultural, and programmatic challenges and opportunities for both institutions. However, there was a sharp contrast between the opinions of the HUH and CNMC residents with respect to the perceived effect of the merger on residency training, patient care, and the individual institutions. Increasing the size and diversity of CNMC's resident pool and the granting of accreditation for the community health track were positive outcomes, but the magnitude of the institutional change process and the disruption to residents' routines and schedules were significant challenges. The merger served as an impetus to embed cultural competency guiding principles and expectations into the organizational fabric of the combined residency program.     

Sharing mental health care. Training psychiatry residents to work with primary care physicians

Overcoming problems in communication between psychiatry and primary care requires new models of collaboration. Their success will depend upon the ability of participants to work productively with each other, which will require psychiatry residency programs to offer appropriate preparation for future graduates in working with primary care physicians. This article, based on the training at McMaster University in Hamilton, Ontario, describes a brief curriculum for training psychiatry residents to work effectively with primary care physicians that can be easily integrated with current training rotations and looks at adjustments academic departments need to make to support such programs.     

Family practice training over the first 26 years: a cross-sectional survey of graduates of the University of Washington Family Practice Residency Network.

PURPOSE: To describe the current practice setting, scope of practice, and adequacy of residency training of a large cohort of family practice (FP) residency graduates. METHOD: In February 2000, questionnaires containing 120 demographic, practice, and training items were mailed to 1,498 graduates (1973-1999) of the University of Washington Family Practice Residency Network. RESULTS: A total of 983 (71%) graduates completed the survey. Of the 870 who were currently practicing family physicians, 38% were women, 73% worked full-time, 45% practiced in FP groups, and 97% were board certified in FP. A total of 37% practiced in communities of fewer than 25,000 residents, and 29% practiced in federally designated health provider shortage sites. Most cared for their patients in the hospital: 79% for adult medical patients, 54% for adult ICU/CCU patients, and 71% for children. Most provided maternity care: 63% delivered babies and 58% assisted at cesarean sections (12% as primary surgeon). Even in cities of over 100,000, 58% delivered babies. Large numbers of responders performed colposcopy, flexible sigmoidoscopy, vasectomy, and minor surgery. A higher proportion of the most recent graduates provided maternity care and performed colposcopy. Most graduates reported that residency training prepared them well. CONCLUSIONS: FP residency training is modeled to prepare primary care physicians to meet the needs of all patients in all communities. These data document the success of this model in producing and sustaining family physicians to fulfill these roles in practice.     

Pediatric residency training on tobacco: review and critique of the literature

OBJECTIVE: To review and critique the research literature on training pediatric residents to address tobacco. METHODS: A Medline search was conducted to identify studies that specifically addressed pediatric residency training on tobacco, and Google Scholar was used to identify articles in which the referenced study was cited. RESULTS: Eight studies that specifically addressed training pediatric residents to intervene on tobacco were identified. Most used active as well as passive approaches to training. Baseline data underscored the importance of training future pediatricians to address tobacco. Although the studies differed in size, scope and rigor, they showed that training pediatric residents to address tobacco enhanced residents' ability and likelihood to address tobacco. CONCLUSION: The review documents the importance and value of training pediatric residents to address tobacco, provides suggestions for future research and underscores the need to incorporate training on tobacco into pediatric residency training curriculum.     

A comparison of smoking cessation efforts in African Americans by resident physicians in a traditional and primary care internal medicine residency

Tobacco use causes significant morbidity and mortality among African Americans. Physicians may inconsistently counsel patients against smoking. This retrospective chart review evaluated smoking cessation efforts in African Americans by internal medicine resident physicians in a traditional and a primary care residency program. One hundred twenty-nine African-American patients were evaluated by resident physicians in the traditional internal medicine residency. A tobacco use history was obtained in 84 patients. Twenty-eight patients smoked and two patients were counseled against smoking. Fifty-two African-American patients were evaluated by resident physicians in the primary care residency. A tobacco use history was obtained in 47 patients. Twenty patients smoked and 12 patients were counseled against smoking. There was a statistically significant difference in the rate at which smoking histories were obtained (p = 0.0011) and frequency of counseling against smoking (p < 0.0001). Gender analysis revealed that African-American women were less frequently asked about their smoking history (p = 0.0058) and counseled against smoking (p = 0.0016) by resident physicians in the traditional residency. African-American men received less counseling against smoking (p = 0.055) by resident physicians in the traditional residency. Resident physicians in the primary care residency program demonstrated greater smoking cessation efforts for African American patients. Smoking cessation should be emphasized in all internal medicine residency training programs.     

The geographic relationships between physicians' residency sites and the locations of their first practices

The uneven geographic distribution of physicians has been identified as a significant problem for the delivery of health care services. The present study examined one of the factors that contribute to the distribution of physicians; how far they move from their residency sites to establish their first practices. In 1989, the authors selected a random sample of 701 U.S. residency programs in the ten specialties with the most practitioners, and measured the distance each of these physicians moved to his or her first practice location. Of the 701 programs, 58.5% provided usable information about 2,612 physicians. Of these physicians, over 40% had moved less than 10 miles from their residencies, and over 50% had moved less than 75 miles. Comparisons among the physicians from the various specialties showed that the primary care physicians moved significantly shorter distances than did those from the other specialties. In the last two decades, many efforts have been made to increase the geographic distribution of physicians. The evidence from this study suggests that so far as the distances that physicians move from their practice sites are concerned, little has changed. Recent graduates of residency programs show no more tendency to move far from their residency sites than did their counterparts 30 years ago, as reported in the literature.     

The impact on rural New Mexico of a family medicine residency.

PURPOSE: To determine the impact on rural New Mexico of the large, decentralized University of New Mexico (UNM) family medicine residency. METHOD: A cross-sectional study was conducted of all 317 residency's graduates from 1974 to 2004. Location of current practice was correlated with the residents' gender, ethnicity, medical school of origin, and whether most training took place in the urban program or one of three rural programs. The residency's impact on rural communities was assessed. RESULTS: There was no significant gender difference between graduates who went into urban or rural practice. Compared with non-minority graduates, a significantly greater percentage of ethnic minority graduates were in rural and urban New Mexico practices and fewer in out-of-state practices. A greater percentage of graduates who had been medical students in New Mexico practiced in both rural and urban New Mexico areas compared with graduates of out of state medical schools. Finally, a greater percentage of graduates from the three rural family medicine residencies remained in the state and practiced in rural areas compared with graduates from the urban program. The graduates' contributions to the school of medicine and to rural New Mexico are described. CONCLUSIONS: Graduates of UNM's family medicine residency have contributed significantly to the state's rural health workforce. Ethnic minority status, graduation from New Mexico's medical school, and training in one of the three rurally based residencies favored in-state and rural retention, while gender had no significant effect. The rural orientation of the residencies offered rural communities economic benefits.     

Models of mental health training for primary care physicians

Of the 15% of the population with DSM III diagnosable disorders, 54% are seen exclusively by their primary care physician or by other health professionals. To understand how primary care physicians are prepared for this task the authors attempted to develop a taxonomy of mental health training programs for primary care physicians by: review of the literature, interviews with program sponsors, review of NIMH training grants, and site visits to teaching programs. From this process six program types were defined: consultation, liaison, bridge, hybrid, autonomous, and postgraduate specialization. The characteristics and emphasis of these model types are described as well as program needs for future training. Competence in psychosomatic medicine, psychophysiologic reactions, and the interactions of biologic, psychologic, and social factors in health and disease can be imparted to primary care physicians by such mental health training program designs.     

Foreign medical graduates and the issue of substantial disruption of medical services

Provisions of the 1976 Health Professions Educational Assistance Act may result in a substantial disruption of medical services provided by foreign medical graduates in United States residency training programs. Estimates of the effect of the Act indicate that between one third and two thirds of foreign graduates receiving visas annually will not qualify for admission, under the new provisions. Results of a recent study show, furthermore, that foreign medical graduates constitute a majority of the residents in 23 per cent of the hospitals with residency programs. Transition to a decreased dependence on foreign graduates may be facilitated through the waiver of two provisions relating to exchange visitors. Projected numbers of United States medical graduates and citizens receiving medical education abroad will not be enough to fill the gap created by the ultimate reduction in alien physicians. United States residency programs will have to develop alternative sources of residents to continue operating at current levels.     

Evidence for longitudinal ambulatory care rotations: a review of the literature.

PURPOSE: Block ambulatory rotations and longitudinal ambulatory care experiences are now common in U.S. medical schools, but little is known about their efficacy. Through a structured review of the medical literature from 1966 through March 2000, the authors summarize the characteristics of, the evidence for, and the evaluation of longitudinal ambulatory care rotations. METHOD: The authors searched Medline using the terms "outpatients," "continuity of patient care," "ambulatory care," "mentors," "preceptorship," "graduate medical education," "curriculum," and "clinical clerkship" cross-matched to "medical students" and "internship and residency" for literature published from 1966 through March 2000. They narrowed the list to only articles containing empirical outcome data focusing on medical students' experiences in longitudinal ambulatory care rotations. Each study was scored to assess its strengths and weaknesses. RESULTS: Seven articles met the search criteria. The articles identified the benefits of longitudinal ambulatory care experiences, including developing effective patient interactions and understanding chronic diseases. There were little or no differences in the students' overall knowledge acquisition when those with longitudinal experiences were compared with those in block rotations. DISCUSSION: Although longitudinal ambulatory care experiences are now common in medical schools, evidence supporting their widespread implementation is sparse. Few studies employ rigorous methods to evaluate educational outcomes. Research to identify benefits and costs, improve the quality and consistency of the students' experiences, and develop other innovative ways of teaching and learning ambulatory care is needed.     

Psychosocial training in U.S. internal medicine and family practice residency programs.

PURPOSE: Competence in the psychosocial aspects of medical care is necessary for primary care physicians to function effectively. This study investigated the psychosocial training internal medicine and family practice residents receive in U.S. programs. METHODS: In 1996, program directors of all U.S. internal medicine (IM) and family practice (FP) residency programs were surveyed regarding the format, content, and quantity of psychosocial training provided in their programs, their opinions on topics related to psychosocial training, and demographics of their programs. RESULTS: The response rate was 61%. Ninety-nine percent of FP and 62% of IM program directors reported requiring at least one psychosocial training experience. Family practice programs required an average of 352 hours (SD +/- 175; range 27-2,664) of psychosocial training compared with 118 hours (SD +/- 272; range 0-1,050) for IM programs. Most IM and FP program directors expected residents to achieve at least basic competency in virtually all psychosocial topic areas; however, FP programs provided a greater range of psychosocial experiences. FP program directors most often identified psychologists and IM program directors most often identified internists as providing the most psychosocial training in their programs. Both IM and FP program directors considered lack of curricular time to be the main obstacle to development of psychosocial training. CONCLUSION: Residents' competence in psychosocial areas is important to both IM and FP program directors. However, content and time devoted to psychosocial training vary considerably both within and between program types.