Family Medicine Abstracts
Volume 41 Issue 5
May 2009
Abstracts
Epistemology and Uncertainty in Primary Care: An Exploratory Study
BACKGROUND AND OBJECTIVES: Primary care is an endeavor marked by breadth, complexity, and more clinical uncertainty than all non-primary care specialties except psychiatry. This is significant, as uncertainty is associated with a variety of troublesome economic and clinical indicators. Researchers have identified the three types of cognitive resources needed to combat uncertainty (technical, personal, or conceptual), as well as the affective stress reactions physicians have when confronted with uncertainty. In this study, we explored the relationship between primary care physicians' stress reactions to uncertainty and the conceptual resource of epistemology. METHODS: Using Likert-type measures of epistemology and stress reactions to uncertainty, we conducted a cross-sectional survey with 78 board-certified and resident physicians in primary care. A simple bivariate regression analysis was performed to identify the relationship between epistemology and stress reactions to uncertainty (Model 1), and a multivariate regression analysis was performed to test for the independent effect of epistemology on stress reactions to uncertainty while controlling for gender, specialty, and professional development status (Model 2). RESULTS: Physician epistemology and stress reactions to uncertainty were significantly related in both models. CONCLUSIONS: Among primary care physicians, a biopsychosocial epistemology is associated with less stress reactions to uncertainty, and a biomedical epistemology is associated with more stress reactions to uncertainty.
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Your Life in Their Pocket: Students' Behaviors Regarding Confidential Patient Information
BACKGROUND AND OBJECTIVES: Physicians are sometimes poor at observing patient confidentiality. Medical students have access to patients and their medical records, but there is little known about how well students respect patients' confidentiality. Our objective was to study how medical students deal with confidential patient information. METHODS: Qualitative research methods (focus groups, semi-structured interviews, and direct peer observation of student activity) were used to explore the approach of medical students to patient confidentiality in a British medical school. RESULTS: We interviewed 32 students, held focus groups involving 24 students, and undertook direct observation of student activity. The main themes derived from the data included the context within which students practice, variation in students' attitude and behavior toward patient confidentiality, and the dissonance between confidentiality theory and practice. CONCLUSIONS: While many students practiced in a professional manner, several reported markedly suboptimal performance in themselves or others. These behaviors appear to be driven by students' own professionalism and behavior learned from senior colleagues. While new technologies pose some particular threats to confidentiality, paper records seem just as vulnerable.
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Teaching First-year Medical Students to Apply Evidence-based Practices to Patient Care
BACKGROUND AND OBJECTIVES: Our objective was to describe and evaluate an educational intervention for teaching preclinical medical students enrolled in a family medicine preceptorship to use evidence-based medicine (EBM) techniques. METHODS: In a brief workshop, 94 preclinical students, enrolled in a 4?week family medicine preceptorship, learned an EBM approach to clinical decision making. Students were responsible for completing four patient case summaries to document that they had searched selected databases and obtained feedback from their preceptors. We then evaluated (1) the percent of students documenting EBM processes, (2) the students' perceived self?efficacy, (3) the level of the students' EBM learning, and (4) preceptors' attitudes toward using the EBM project as the focus of their feedback. RESULTS: All students succeeded in identifying the factual knowledge that they had used to convert information from patient encounters into searchable clinical questions. The preceptors provided case?specific, written feedback to all students. Students gave lesser ratings of importance to EBM and self?efficacy in using EBM after the preceptorship as compared to after the brief introductory workshop. Preceptors acknowledged that the project helped them to focus their feedback and to reconsider patient management practices. CONCLUSIONS: Students learned to use an EBM process and became more familiar with and more realistic about their self?efficacy in using EBM. Preceptors and preclinical medical students can learn and hone EBM skills together.
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A Model for a Standardized National Family Medicine Graduate Survey
BACKGROUND AND OBJECTIVES: Accreditation requirements mandate that family medicine residency programs perform surveys of graduates. As part of the Preparing the Personal Physician for Practice (P4) Project, we developed a model for a standardized national graduate survey to be used to assess practice characteristics of graduates, including the implementation of features of the Patient-centered Medical Home (PCMH). METHODS: We conducted a content analysis of residency graduate surveys from the 14 programs involved in the P4 project to identify common elements of importance to residencies. We then designed a new graduate survey as a core measure of the P4 Project. It included practice characteristics, assessment of training, and the status of features of the PCMH. RESULTS: Categories of variables common to the graduate surveys of the P4 programs included physician and practice characteristics, work load, scope of practice, career satisfaction, and assessment of training. We found variability among programs in the number of procedures and residency content areas listed on any individual program survey, with the number of procedure ranging from 0--21, and the number of content areas ranging from 0--61. The only PCMH feature included on any P4 program survey was the status of an electronic medical record. CONCLUSIONS: Graduate surveys from individual residency programs vary widely. Using a standardized national survey instrument would provide important information to understand the national practice characteristics and scope of practice in family medicine as well as to track the implementation of PCMH features among residency graduates.
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BACKGROUND AND OBJECTIVES: Six family medicine residency programs in the United States collaborated on the development and implementation of an integrative family medicine (IFM) program, which is a postgraduate training model that combines family medicine residency training with an integrative medicine fellowship. This paper reports on effects of IFM on residency programs and clinical systems in which it was implemented. METHODS: We used the Integrative Medicine Attitudes Questionnaire (IMAQ) to assess participants' attitudes toward integrative medicine before and after the program was implemented. We assessed residency program recruitment success before and after the program was implemented. We conducted interviews with key informants at each program to evaluate the effects of the IFM on the six participating residency programs. RESULTS: IMAQ scores demonstrated a significant increase in the acceptance of integrative medicine after implementation of IFM. Recruiting data showed that participating programs filled at a rate consistently above the national average both before and after implementation. Analysis of interview data showed that programs became more open to an integrative medicine (IM) approach and offered a wider range of clinical services to patients. CONCLUSIONS: Our mixed-methods strategy for evaluation of IFM showed that implementing the program increased acceptance of IM, did not affect residency fill rates, and increased use of IM in clinical practice. The combination of quantitative and qualitative methods was an effective strategy for documenting the "systems level" effects of a new educational program.
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Opportunities for the Use of Decision Aids in Primary Care
BACKGROUND AND OBJECTIVES: Shared decision making (SDM) is part of a larger movement for patient-centered approaches to care. SDM can be facilitated through the use of decision aids (DA), which are evidence-based tools designed to transmit information on topics suitable for SDM. They are intended to facilitate the process of patients arriving at an informed, values-based choice in partnership with physicians. Research indicates that SDM and the use of DA are underutilized. This study evaluated SDM and DA in primary care. METHODS: Adult patients presenting for chronic disease follow-up to one of four participating primary care health centers were recruited over 16 months. Visit discussions were audiorecorded, transcribed, and coded using Davis coding. Discussion comments were coded for type of SDM (with and without DA) and topics matched against two DA registries. RESULTS: Forty-four unique patient visits were recorded. Shared decision activities on 15 topics were found in 34 discussions, across 27 (61%) of the visits. DA use did not occur in any visit. Fifteen (34%) visits included topics with peer-validated, freely available DA. CONCLUSIONS: Even when shared decision making occurs, DAs are rarely used. Research is needed to identify and reduce barriers to using DAs in primary care.
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The Physician's Response to Climate Change
Climate change will have an effect on the health and well-being of the populations cared for by practicing physicians. The anticipated medical effects include heat- and cold-related deaths, cardiovascular illnesses, injuries and mental harms from extreme weather events, respiratory illnesses caused by poor air quality, infectious diseases that emanate from contaminated food, water, or spread of disease vectors, the injuries caused by natural disasters, and the mental harm associated with social disruption. Within several years, such medical problems are likely to reach the doorsteps of many physicians. In the face of this reality, physicians should assume their traditional roles as medical professionals, health educators, and community leaders. Clinicians provide individual health services to patients, some of whom will be especially vulnerable to the emerging health consequences of global warming. Physicians also work in academic medical institutions and hospitals that educate and provide continuing medical education to students, residents, and practitioners. The institutions also produce a measurable carbon footprint. Societies of physicians at national, state, and local levels can choose to use their well-developed avenues of communication to raise awareness of the key issues that are raised by climate change as well as other environmental concerns that have profound implications for human health and well-being.
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