Background and Objectives: In the 1990s, the Residency Review Committee for Family Practice (RRCFP) and the American Board of Family Practice used the development of rural training programs as a strategy to bridge training experiences across urban referral centers and rural community hospitals. These programs are relatively small and attract trainees who are predisposed to rural practice. Aggregating data from several programs yields insight about their challenges and their ability to produce graduates who enter rural practice.

Methods: This descriptive analysis is based on self-reported data from a 1996 survey mailed to the residency program directors of rural training programs, identified by the RRCFP office as one-two programs.

Results: More than half of the rural training programs surveyed were located in health professions shortage areas, most in communities with little urban influence. These programs are equally likely to be sponsored by university- or community-based residency programs. Most (75%) placed two or fewer residents per year in the rural site; minorities accounted for 4% of placements. Thirty percent of programs report unfilled positions. Seventy-five percent use televideo communications and find experiences in surgery and obstetrics relatively easy to arrange but dermatology and critical care difficult. Seventy-six percent of graduates enter rural practice after graduation.

Conclusions: This survey suggests that family practice rural one-two residencies are meeting the goal of providing trainees with a rural immersion experience, in anticipation of selecting rural practice after graduation.

Special Series: Rural Residency Tracks
(Fam Med 1998;30(2):90-3.)

A Process for Developing a Rural Training Track
James R. Damos, MD; Louis A. Sanner, MD, MSPH; Carrol Christman, MA; Janet Aronson, MSSW; Sharon Larson, MBA

Background and Objectives: This article describes the process used by the University of Wisconsin-Madison Family Practice Residency Program to establish its first rural training track (RTT) in Baraboo, Wis. The process includes 1) establishing a core planning group to develop rural site selection criteria with specifications on distance traveled, faculty composition, teaching commitment, rural hospital capabilities, and availability of subspecialty teaching, 2) involvement of the state Area Health Education Center, 3) budget planning, 4) telecommunications plans, including e-mail, library search, and Internet connectivity, 5) creation of a residency curriculum in collaboration with the rural site’s faculty and staff, 6) preparing an accreditation document to submit to the Residency Review Committee, and 7) faculty development programs for rural faculty. The program then participates in the National Residency Matching Program with an independent Match number.

Special Series: Rural Residency Tracks
(Fam Med 1998;30(2):94-9.)

Reported Comfort With Obstetrical Emergencies Before and After Participation in the Advanced Life Support in Obstetrics Course
Harry A. Taylor, MD; William R. Kiser, MD

Background and Objectives: Prior research has demonstrated a change in Advanced Life Support in Obstetrics (ALSO) course attendees’ reported comfort with managing specific obstetrical emergencies and procedures before and immediately after participation in an ALSO course. Assessment of longer-term stability of these changes has not been performed. This study measured changes in comfort with obstetrical emergencies and reported practice patterns 1 year after ALSO training.

Methods: ALSO course attendees (275) were given a grounded Likert scale survey measuring reported comfort with the management of specific obstetrical emergencies and procedures before, immediately after, 6 months after, and 1 year after participation in an ALSO course. Practice patterns were also surveyed. Paired data were analyzed using the Kruskal-Wallis one-way ANOVA test at a 95% confidence interval for two-tailed significance.

Results: ALSO course participants reported a significant increase in their comfort with the management of each of 15 obstetrical emergencies and procedures taught in the ALSO curriculum. Reported comfort remained high at 6 months’ and 1-year follow-up and was accompanied by a statistically significant change in reported practice patterns; more participants performed, in their practice 1 year after completion of ALSO training, amnioinfusion, vacuum-assisted vaginal delivery, and ultrasound for determining fetal position and placental location.

Conclusions: Affective learning is important in translating knowledge and skills into the practice of medicine. Our study demonstrates that participation in the ALSO course increases participants’ knowledge in the affective domain of learning.

Educational Research and Methods
(Fam Med 1998;30(2):103-7.)

Quality of Student Learning and Preceptor Productivity in Urban Community Health Centers
M. Diane McKee, MD; Penny Steiner-Grossman, EdD, MPH; William Burton, MA; Michael Mulvihill, DrPH

Background and Objectives: Clinicians in community health centers find it difficult to balance the demands of increased productivity and effective teaching. We hypothesized that precepting third-year students would decrease clinical productivity and that many elements related to the quality of the learning experience (eg, amount of patient contact, student autonomy) would be adversely affected by pressure to see increasing numbers of patients.

Methods: Students and preceptors in a 6-week family medicine clerkship completed daily surveys that measured the presence of quantifiable elements of the ambulatory teaching experience. They also rated the overall quality of learning during each session.

Results: For 62 sessions for which both students and preceptors completed evaluations, students rated the overall quality of learning more highly than preceptors. For students, the elements most positively associated with quality of learning were total teaching time and the frequency with which family issues were raised. For preceptors, the elements that predicted quality of learning were the number of patients that students saw independently and total teaching time. The clinical productivity of preceptors did not differ for sessions with and without a student.

Conclusions: Preceptors can be effective teachers who encourage student autonomy and who model behaviors central to family practice, without decreasing productivity.

Educational Research and Methods
(Fam Med 1998;30(2):108-12.)

Promoting Medical Student Involvement in Primary Care Research
Ann O’Brien Gonzales, PhD; John Westfall, MD, MPH; Gwyn E. Barley, PhD

Background and Objectives: As the growth of primary care continues, the need for strengthening the scientific foundations of practice becomes more pressing. Although there is general agreement on the importance of promoting primary care research by medical students, little has been reported on how this can be accomplished. The goal of the program described is to involve medical students in primary care research.

Methods: Over the last 7 years, the Department of Family Medicine at the University of Colorado has promoted the involvement of medical students in primary care research through a program consisting of five elements: 1) a student development program (the Family Medicine Scholars Program), 2) financial support for student research, 3) a core of faculty mentors, 4) a strong coordinating effort by the predoctoral education office, and 5) research agendas geared to student schedules.

Results: The number of students involved in primary care research, presentations, and publication of papers by students has increased since we initiated our medical student research program 7 years ago.

Conclusions: The elements discussed have proven successful at increasing student participation in primary care research.

Educational Research and Methods
(Fam Med 1998;30(2):113-6.)

US Family Physicians’ Experiences With Practice Guidelines
Marie Wolff, PhD; Douglas J. Bower, MD; Anne M. Marbella, MS; James E. Casanova, MD

Background and Objectives: Practice guidelines were developed to improve medical outcomes and cost-effectiveness. The experiences of family physicians, who may need to use multiple guidelines in their practices, are crucial for effective development and implementation of practice guidelines. We surveyed a national sample of US family physicians about factors that affect their adoption and use of practice guidelines.

Methods: We mailed a structured survey to a national random sample of 400 family physician members of the American Academy of Family Physicians.

Results: The response rate was 51%. Most respondents (69%) reported a positive attitude about practice guidelines, but only 44% reported using any guidelines. More younger physicians thought that guidelines could be useful tools. Most preferred guidelines that could be modified (87%) and that were no longer than two pages. Only 27% of respondents knew where to locate a guideline on a particular topic. Forty-three percent of respondents reported that it would be useful if guidelines were a component of an electronic medical record.

Conclusions: If guidelines are to be used by practicing family physicians, a generalist perspective needs to be considered in future guideline development and implementation. Younger physicians had more positive attitudes toward guidelines.

Clinical Research and Methods
(Fam Med 1998;30(2):117-21.)

The Relationship Between a Patient’s Spirituality and Health Experiences
J. LeBron McBride, PhD, MPH; Gary Arthur, EdD; Robin Brooks, MA; Lloyd Pilkington, MEd

Background and Objectives: The relationship between spirituality and health is a new frontier in medicine. This study is a preliminary investigation into the relationship between a patient’s experience of overall health, physical pain, and intrinsic spirituality.

Methods: We used a stratified, random sample of 462 patients at a family practice residency clinic. The Index of Core Spiritual Experiences (INSPIRIT) measured intrinsic spirituality, and Dartmouth Primary Care Cooperative Charts measured overall health and pain. Pearson correlations tested the association between health, pain, and spirituality. Patient scores on the INSPIRIT were then placed into three groups (high, medium, and low levels of intrinsic spirituality). ANOVA tested for significant differences in health and pain.

Results: We collected information from 442 of the patients surveyed (95%). We found significant correlation between patient health and spirituality. Significant differences were also found in both overall health and physical pain, based on the three levels of spirituality. Gender differences were only significant for overall health, not for patient pain.

Conclusions: Our results suggest an association between intrinsic spirituality and a patient’s experience of health and pain. Assessment of spirituality may be important for family physicians to consider as a supplement to patient interviews.

Clinical Research and Methods
(Fam Med 1998;30(2):122-6.)

Medical Education in a Changing World: Thoughts From California
John Zweifler, MD, MPH; Jonathan Rodnick, MD

Background and Objectives: Medical education has been buffeted by the frenetic changes in our health care delivery system. This commentary focuses on six major issues facing family practice training programs caring for underserved populations in California: 1) The patient base for training programs is eroding. 2) There is no or limited funding for graduate medical education (GME) in Medicaid managed care programs. 3) There are barriers to using residents in managed care systems. 4) Disproportionate share funding from Medicaid for hospitals caring for poor and underserved patients does not support medical education. 5) Capitated Medicare and Medicaid programs are siphoning off dollars meant for GME. 6) Consolidation in the health care market is threatening medical education training sites. To address these issues, primary care GME programs should work with community-based sites so both can increase patient care, educational activities, and revenue in this managed care era. At the same time, community-based training sites in primary care GME programs must redesign their delivery systems to provide efficient, cost-effective care. The result will be better access for primary care patients and more appropriate training for our residents. Family medicine educators should become increasingly involved at the local, state, and national levels to ensure that GME funding directly supports training and is not relegated to being a by-product of patient care.

Commentary
(Fam Med 1998;30(2):127-33.)