Family Medicine Abstracts
Volume 44 Issue 1
January 2012
Abstracts
January 2012
Abstracts
How Do Medical Students View the Work Life of Primary Care and Specialty Physicians?
BACKGROUND AND OBJECTIVES: Student perceptions of day-to-day physician work life, and relationships between these perceptions and specialty choices, have not been quantitatively explored. The study's purposes were to measure student perceptions of primary care and specialist physician work life, including administrative burden, time pressures, autonomy, and relationships with patients, to determine whether senior students' perceptions vary from junior students' perceptions and to determine whether students with primary care career plans view primary care work life differently than their peers. METHODS: A cross-sectional anonymous survey was offered to all students at three allopathic US medical schools between 2006 and 2008. RESULTS: Of 1,533 eligible students, 983 submitted usable surveys (response rate 64.1%). Students viewed the day-to-day work life of all physicians negatively but viewed primary care physician work life more negatively. Senior students viewed specialist work life more positively and primary care work life more negatively than junior students. Students planning primary care and specialist careers had similar views of primary care and specialist work life. CONCLUSIONS: Students have negative views of the work life of all physicians, especially primary care physicians. Students planning careers in primary care share this negative view of their future work life, suggesting that their career choices are not based on different work life perceptions.
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Epistemology and Uncertainty: A Follow-up Study With Third-year Medical Students
BACKGROUND AND OBJECTIVES: Prior research results indicate a relationship between medical epistemology (ie, how a physician organizes and prioritizes the biological and psychosocial data of a patient presentation) and stress reactions to uncertainty among primary care physicians. However, little is known about when this relationship forms. The purpose of this study was to begin answering this question by exploring the relationship between medical epistemology and stress reactions to uncertainty among a group of 89 third-year medical students from the class of 2010 of a three-campus state medical school located in the southwestern US. METHODS: Data from Likert-type measures of medical epistemology and stress reactions to uncertainty were extracted from course evaluation information that was collected at the start (T1) and end (T2) of a continuity clinic experience that spanned most of the students' third year. Using these data, the authors conducted a simple bivariate regression analysis to identify the relationship between medical epistemology and stress reactions to uncertainty (Model 1), and a multivariate regression analysis to test for the independent effect of medical epistemology on stress reactions to uncertainty while controlling for gender and specialty interest (Model 2). These two regression models were calculated for both the T1 and T2 data sets. RESULTS: The two regression models at T1 indicated no significant relationships between medical epistemology and stress reactions to uncertainty; however, the two regression models at T2 indicated that a biopsychosocial epistemology is associated with less stress reactions to uncertainty, and a biomedical epistemology is associated with more stress reactions to uncertainty. CONCLUSIONS: The third year is an opportune time for medical educators to help shape and develop students' medical epistemology and stress reactions to uncertainty.
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Are Students Less Likely to Report Pertinent Negatives in Post-encounter Notes?
BACKGROUND AND OBJECTIVES: In completing post-encounter notes (PENs), students are believed to under-report about 30% of the important information obtained in the medical history. The resulting incomplete clinical notes can contribute to adverse patient care and medicolegal outcomes. We hypothesized that pertinent negative items would be more likely to be under-reported than positive items. We compared reporting rates for pertinent positive and negative items on two cases in a clinical skills assessment (CSA) taken by all 55 third-year students. Based on standardized patient (SP) checklists, students obtained 87% of both positive and negative items. Scoring of PENs found significant differences in the reporting rates for positive (75%) and negative (52%) items. These results were consistent for each case. Students appear to be able to elicit pertinent negative information from patients but, although these items may be crucial in the medical history, they are significantly more likely than positive items to be omitted from the clinical note.
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BACKGROUND AND OBJECTIVES: Given the growing presence of Patient-centered Medical Home practices and the need for patient participation, it is concerning that tools to improve patient participation are not widely used in primary care. Despite demonstrated effect on decision quality and patient satisfaction, decision aids (DAs) are not broadly utilized. We conducted focus groups to examine the use of DAs and uncovered barriers to greater DA utilization in primary care. METHODS: The University of California, San Diego family medicine clinics use an integrated process to prescribe DA videos. We conducted provider and patient focus groups to explore use of DAs in three clinics. Using a qualitative phenomenological design, we analyzed thematic content using immersion techniques. RESULTS: Focus group discussions identified six categories: patient benefits, physician benefits, process improvements needed, reasons DAs are prescribed, barriers to watching DAs, and the role of the DA. These categories encompassed 21 themes. Four themes were salient for improving DA utilization: follow-up process needs improvement, prescribing process needs improvement, patients were unclear regarding each DA's purpose, and patient benefits. CONCLUSIONS: While previous studies have described expected barriers to hypothetical DA distribution, our analysis reveals barriers reported by physicians, staff, and patients based on actual experience in practice. Decision aids can improve patient participation in health decisions. However, physicians and patients have to recognize a need for these tools before they will be adopted in practice.
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The Annual Program Review of Effectiveness: A Process Improvement Approach
BACKGROUND AND OBJECTIVES: All residencies and fellowships are required by the Accreditation Council for Graduate Medical Education (ACGME) and local institutional policy to conduct an annual program review of educational effectiveness. However, a number of family medicine residencies were cited for having an inadequate annual review or for failing to document the review in 2008. The ACGME and university offices of graduate medical education provide program directors some guidance on conducting and documenting annual program reviews, but few articles describe a detailed process for such a review. In this article, the authors describe the systematic process their program uses to conduct and document an annual program review and argue that the annual program review is an excellent way of modeling quality improvement to residents and showing residents and faculty that their input helps improve the residency and the residents' educational experiences. The article also describes metrics included in the process and tells how resident and faculty participation is integrated in the review. Specific outcomes of the process are also described. The authors believe that other residency programs and fellowship programs can adapt this process to conduct annual reviews that improve educational and clinical outcomes.
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Why Do Some Eligible Families Forego Public Insurance for Their Children? A Qualitative Analysis
BACKGROUND AND OBJECTIVES: Central to health insurance reform discussions was the recurring question: why are eligible children not enrolled in public insurance programs? We interviewed families with children eligible for public insurance to (1) learn how they view available services and (2) understand their experiences accessing care. METHODS: Semi-structured, in-depth interviews with 24 parents of children eligible for public coverage but not continuously enrolled were conducted. We used a standard iterative process to identify themes, followed by immersion/crystallization techniques to reflect on the findings. RESULTS: Respondents identified four barriers: (1) confusion about insurance eligibility and enrollment, (2) difficulties obtaining public coverage and/or services, (3) limited provider availability, and (4) non-covered services and/or coverage gaps. Regardless of whether families had overcome these barriers, all had experienced stigma associated with needing and using public assistance. There was not just one point in the process where families felt stigmatized. It was, rather, a continual process of stigmatization. We present a theoretical framework that outlines how families continually experience stigma when navigating complex systems to obtain care: when they qualify for public assistance, apply for assistance, accept the assistance, and use the public benefit. This framework is accompanied by four illustrative archetypes. CONCLUSIONS: This study provides further insight into why some families forego available public services. It suggests the need for a multi-pronged approach to improving access to health care for vulnerable children, which may require going beyond incremental changes within the current system.
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Incoming Resident Experience and Comfort With Procedures Designated as "Basic"
BACKGROUND: Recent consensus guidelines have recommended uniformity in procedural training in family medicine residency programs. The consensus documentation suggestions are based on expectations of procedural training prior to residency. Few studies have evaluated the perceived baseline level of procedural competency prior to residency training. METHODS: Twenty incoming PGY-1 residents completed a "procedural experience survey," asking respondents to identify their prior experience and current comfort levels with 19 "basic" procedures. RESULTS: For seven procedures, no prior experience was the most common response. For 15 of the 19 procedures, at least one respondent reported no prior experience. The residents' self-reported comfort levels varied widely for each procedure. CONCLUSIONS: The survey results showed that experience and comfort with procedures often performed in family medicine varies widely among incoming residents. This raises the question of whether documentation of resident competence in these procedures should be recommended as a baseline and monitored throughout residency training.
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