October 1997, Vol. 29, No. 9
 
Skills That Iowa Family Physicians Desire in a New Physician Partner
George R. Bergus, MD; Barcey T. Levy, PhD, MD; Christina S. Randall, PhD; Jeffrey D. Dawson, PhD; Gerald J. Jogerst, MD

Background and Objectives: The importance of specific skills in primary care continues to be debated. As a result, there is not consensus on which skills need to be stressed during residency training. Our project asked community-based family physicians to rate the importance of specific skills in a new family physician partner.

Methods: Data were collected through a cross-sectional survey of all active members of the Iowa Academy of Family Physicians. Participants were surveyed by mail, using a list of 83 skills pertinent to primary care. Physicians were asked to rate the importance of a new member of their practice having the individual skills on this list.

Results: A total of 546 family physicians (67%) completed questionnaires. Fourteen skills (seven cognitive and seven psychomotor) were reported to be "essential" or "very important" by at least 80% of the physicians. A total of 43 skills were rated as "essential" or "very important" by at least 50% of responding family physicians. Many of the hospital-based procedural skills, particularly those used in an intensive care setting, were rated as less important. The importance ratings of many skills were associated with the physicians' ages, size of their primary hospitals, and availability of other medical specialties.

Conclusions: Family physicians tended to rate office-based procedural skills, counseling skills, and management skills as "essential or very important" to their practices. These rating might be used to guide residency training in family practice.

Educational Research and Methods
(Fam Med 1997;29(9):618-24.)

Attitudes of Family Practice Residency Program Directors Toward Mandatory Preemployment Drug Testing
Herbert F. Laufenburg, MD; Beth A. Barton, PhD

Background and Objectives: As health care institutions adopt policies on substance use and abuse and mandatory substance abuse testing in the workplace, applicants for house staff positions may become the subjects of testing as a requirement for acceptance into a residency program. This study attempted to learn what directors of family practice residency programs feel about mandatory preemployment drug testing and its effect on house staff recruitment.

Methods: We surveyed the directors of 420 US family practice residency programs, as listed by the American Academy of Family Physicians, in November 1994. All programs (community based, university affiliated, university based, and military) were included in the survey.

Results: A total of 308 (73%) program directors responded. Of these, almost half disagreed with mandatory substance abuse testing and felt it should not be a condition of acceptance for a house staff position. Eighty-eight percent believed that the existence of a policy did not hinder recruitment. None felt it was an enhancement.

Conclusions: Preemployment drug testing for potential house staff remains a controversial issue, and it is unlikely that it will be universally implemented in the near future.

Educational Research and Methods
(Fam Med 1997;29(9):625-8.)

Documenting Resident Procedure and Diagnostic Experience: Simplifying the Process
Robert A. Baldor, MD; James Broadhurst, MD

Background and Objectives: The Residency Review Committee (RRC) requires documentation of family practice residents' procedural and diagnostic experiences. Further, hospital privileging is frequently based on documentation of prior clinical experience. Residency programs need a user-friendly (ie, resident-friendly) mechanism for collecting data and generating reports to document these experiences. This paper outlines a simplified, user-friendly method of documenting resident procedural and diagnostic experiences.

Methods: We developed a pocket-sized, optically scannable card for data input. This is coupled with a computerized database with report generation capability. The system is based on diagnostic clusters to further simplify the data input process.

Results: The system's setup costs are about $10,000. Annual maintenance and operational fees are about $5,000. After instituting the system, the number of residents submitting documentation information increased substantially.

Conclusions: This system meets both RRC and potential clinical privileging requirements and provides a useful tool for guiding resident evaluation and developing appropriate training opportunities during the latter half of the residency. Simplified, accurate documentation may allow for comparisons among residents at various levels-program, state, and national.

Educational Research and Methods
(Fam Med 1997;29(9):629-33.)

Home Visit Program for Teaching Elder Abuse Evaluations
Gerald J. Jogerst, MD; John W. Ely, MD, MSPH

Background and Objectives: A home visit program was designed to teach family practice residents how to evaluate patients for elder abuse and capacity (the ability to make one's own decisions).

Methods: Residents assessed potential abuse victims reported to Arizona's Adult Protective Service (APS) in their homes. Written evaluations prepared immediately following each home visit were abstracted for diagnoses (including abuse), recommendations, and patient demographics. Follow-up surveys by APS case workers determined whether the home visit recommendations were accomplished. Graduates of the residency were surveyed about their perceptions of the educational value of the program and their practice characteristics.

Results: The residents evaluated 201 patients. The mean age was 77, and 73% of patients were female. Seventy-five percent were incapacitated, 65% of these because of dementia. Ninety-one percent were abused, and the types of abuse included neglect (69%), exploitation (20%), physical abuse (8%), and unknown (3%). Recommendations were accomplished in the majority of cases: medical advice (68%), services (65%), medical evaluations (58%), guardian (53%), and conservator (52%). Graduates who participated in this program (1985-1992) rated their ability to diagnose elder abuse and to assess the patient's home environment significantly higher than earlier graduates who did not participate in the program (1977-1984). Earlier graduates made more home visits and provided more statements for guardianship than later graduates.

Conclusions: The home visit program gave residents exposure to a population of elderly who were abused, demented, and living at home. This program provided clinical substance to build an effective teaching experience and furnished APS with a needed service.

Educational Research and Methods
(Fam Med 1997;29(9):634-9.)

Evaluating Family Practice Residencies: A New Method for Qualitative Assessment
Jeffrey M. Borkan, MD, PhD; William L. Miller, MD, MA; Jon O. Neher, MD; Robert Cushman, MD; Benjamin F. Crabtree, PhD

Background and Objectives: This study reports on a novel qualitative method for evaluating family practice training programs. Previous evaluation techniques have generally been quantitative in nature and have limited their scope to a few isolated elements of residency education.

Methods: A guest faculty, working in conjunction with local faculty, conducted a site analysis of an East Coast and a West Coast family practice residency. Multiple qualitative techniques were used, including participant observation, focus groups, long interviews, and analysis of key texts. Program strengths and weaknesses were analyzed, and a discrepancy model was used to compare program goals and ideals to the actual training realities. The analysis used a process of immersion/crystallization, and triangulation of the multiple data sources was achieved through repeated comparisons.

Results: This report focuses on the process of the evaluations, rather than on their content. In general, the sites have achieved most of their objectives, but notable limitations are present at both programs. This is particularly apparent in terms of multiple demands on faculty, the lack of a shared vision, and program isolation.

Conclusions: Significant lessons were learned from these initial assessments, which can be used to further refine the method. Comprehensive qualitative reviews may provide unexpected insights and identify program limitations and strengths.

Educational Research and Methods
(Fam Med 1997;29(9):640-7.)

 
The Most Common Dermatologic Problems Identified by Family Physicians, 1990-1994
Alan B. Fleischer Jr, MD; Steven R. Feldman, MD, PhD; R. Carol McConnell

Background and Objectives: Because all family physicians see numerous patients with dermatologic complaints, their education in skin disorders is important. Data are needed to help program directors know which areas of dermatology deserve the most time and emphasis. This study determined what types of skin problems family physicians most commonly diagnose.

Methods: Study researchers analyzed National Ambulatory Medical Care Survey data from 1990 to 1994 for dermatologic diagnoses. We then compared physicians specializing in family practice and its related fields (general practice, family practice sports medicine, and family practice geriatrics) with dermatologists and other physicians.

Results: The most common skin disorders diagnosed by family physicians were dermatitis (16.4% of all diagnoses), pyoderma (13.7%), wart (8%), tinea infection (5.4%), and epidermoid cyst (5.1%). The top 10 most common diagnoses accounted for 65% of all skin-related diagnoses, and the top 20 most common diagnoses accounted for 81.8%. Family physicians more commonly saw patients for infectious processes, infestations, and insect bites, while dermatologists were more likely to see patients for psoriasis, alopecia, and rosacea.

Conclusions: Skin disorders diagnosed by family physicians differ considerably from those diagnosed by dermatologists. Because dermatologists do much of the dermatology teaching of family practice residents, it is important to recognize these dissimilarities to place emphasis on the proper areas of study. Some common or serious conditions, such as psoriasis and melanoma, are not often diagnosed by family physicians and also deserve attention in family practice training programs.

Clinical Research and Methods
(Fam Med 1997;29(9):648-52.)

Control, Compliance, and Satisfaction in the Family Practice Encounter
Denise Wigginton Cecil, PhD; Ita Killeen, MD

Background and Objectives: With the current emphasis on patient-centered interviewing, issues of control behavior have become an important facet for understanding effective physician-patient communication. In this study, we describe how verbal control behaviors are manifested during the clinical encounter and how these control patterns relate to patient satisfaction and compliance.

Methods: Videotaped encounters (n=50) in a family practice residency clinic were transcribed and analyzed using the Relational Communication Control Coding Scheme. In addition, we surveyed patients to assess levels of compliance and satisfaction.

Results: Overall, patients showed assertive control patterns, and physicians manifested patterns of willingness to let patients take control of the conversation. The resulting outcomes showed that when physicians exhibited less control dominance, there was an increase in patient compliance and satisfaction.

Conclusions: The control patterns discovered are consistent with patient-centered viewpoints that encourage the patient's expression of ideas, concerns, and expectations. Increased levels of patient satisfaction and compliance were found when patients more assertively participated in the clinical conversation.

Clinical Research and Methods
(Fam Med 1997;29(9):653-7.)

Patient-Caregiver Functional Unit Scale: A New Scale to Assess the Patient-Caregiver Dyad
Lisa Fredman, PhD; Mel P. Daly, MD

Background and Objectives: This study evaluated the reliability and validity of the Patient-Caregiver Functional Unit Scale (PCFUS), a new instrument to assess the stability or endurance of patient-caregiver dyads.

Methods: Patient-caregiver dyads were recruited from a nursing home (NH) (n=38), a comprehensive geriatric assessment program (CGA) (n=20), and an ambulatory medical clinic (controls) (n=85). Caregivers were eligible if they assisted, or were available to assist, the patient with personal and instrumental activities of daily living, without pay. Data were collected by interviewer-administered questionnaires. Inter-rater and test-retest reliability were evaluated among the CGA sample. Validity was assessed by comparing PCFUS scores among the NH, CGA, and control groups and by correlation of PCFUS scores with other standardized caregiver burden measures.

Results: The PCFUS had excellent inter-rater and test-retest reliability. Mean PCFUS scores were significantly lower (ie, less stable patient-caregiver dyad) in NH than CGA and control caregivers. PCFUS scores were significantly associated with Burden Interview, Perceived Stress Scale, and Geriatric Depression Scale scores and risk factors for caregiver stress (eg, patient's cognitive impairment, disruptive behaviors).

Conclusions: The PCFUS is a short, easily administered measure with good reliability and validity and is applicable to clinical and research settings.

Clinical Research and Methods
(Fam Med 1997;29(9):658-65.)

 
The Health Care Delivery Crisis in Haiti
Arthur M. Fournier, MD; Michel Dodard, MD

Background and Objectives: AThis article documents the history, politics, and economics that have contributed to a health care delivery crisis in Haiti and why family medicine will be crucial for the recovery of Haiti's health care. Since the United Nations intervention, there has been some improvement in health conditions. However, the embargo and political turmoil left little infrastructure on which to build. Developing family medicine, one of the priorities of the Ministry of Health, will reverse traditional forces that favor emigration and specialization and will provide the country with well-trained physicians who can treat most of the common health problems of Haiti. These common preventable and treatable problems are now contributing to short life expectancy and high infant mortality. While the ultimate responsibility for Haiti's health rests with Haitian health professionals, the country has an immediate need for international humanitarian assistance, particularly for general medical care.

International Family Medicine
(Fam Med 1997;29(9):666-9.)

  
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