Educational Research and Methods
(Fam Med 1998;30(6):410-6.)

The Problem-based Medical Audit Program: Influence on Family Practice Residents’ Knowledge and Skills
Gina Ogilvie, MD; Allyn Walsh, MD; Sarah Rice

Background and Objectives: Family physicians need to possess the skills to conduct audits in their own clinical settings to ensure that their patients receive exemplary clinical care. Residency offers an important opportunity for physicians to develop these auditing skills. This study describes the introduction of a problem-based medical audit program at three teaching units in the Department of Family Medicine at McMaster University and the program’s effect on learner knowledge, skills, and attitudes toward the practice audit.

Methods: A survey designed to assess residents’ self-rated knowledge, skills, and attitudes toward practice audits was distributed before and after residents participated in the audit program.

Results: Forty-three residents were surveyed; 33 (76.7%) completed the initial questionnaire and follow-up questionnaire. Residents reported significant improvements in their understanding of the relevance of audits, ability to develop a practice audit question, skills in designing methodology, and skills needed to conduct an audit independently. Residents also reported a moderate increase in their knowledge of statistics needed to complete an audit.

Conclusions: The practice audit program at McMaster University uses a problem-based model to introduce learners to the concept of the clinical audit. The practice audit program successfully improved the residents’ self-reported ability to conduct an audit and heightened their understanding of the importance and relevance of the audit process.

Educational Research and Methods
(Fam Med 1998;30(6):417-20.)

Teaching Outpatient Procedures: Most Common Settings, Evaluation Methods, and Training Barriers in Family Practice Residencies
Victor S. Sierpina, MD; Robert J. Volk, PhD

Background and Objectives: The processes of teaching outpatient procedures in the training of primary care physicians have not been widely studied or standardized. This study identified the most widely used teaching settings, methods of evaluation, and barriers to teaching several key procedures in US family practice residencies.

Methods: A survey was sent to directors of family practice residency programs. Key issues identified in phone survey data of published experts in procedural training were used in developing the survey.

Results: Of the 464 residency directors contacted, 342 (73.7%) returned completed surveys. Results showed that the family practice center (FPC) was the most common setting for this teaching. Faculty observation was used as a principal evaluation method in most programs for all procedures. Several barriers to training were identified as “very” or “moderately” important.

Conclusions: While the FPC is the most frequently used setting for training in procedures, significant limitations include problems of low volume, limited methods of evaluation, scheduling difficulties, and lack of faculty interest and skill. Several internal and external strategies may be used to alleviate these problems.

Educational Research and Methods
(Fam Med 1998;30(6):421-3.)

Teaching Community-oriented Primary Care Through Longitudinal Group Projects
J Donsky; T Villela; M Rodriguez; K Grumbach

Background and Objectives: Though community-oriented primary care (COPC) has been advocated as an effective way of addressing health problems of communities, it is neither widely understood nor frequently practiced. Because COPC requires an extended period of time, as well as an approach and skills not generally learned in medical training, effectively incorporating COPC training into medical education is difficult and not frequently attempted. This paper describes a COPC curriculum for family practice residents based on required participation in a longitudinal group project.

Methods: Residents participated in successive groups that completed a COPC project over a 2-year period. Twenty-two of 26 PGY-2 residents completed an attitude and knowledge test before and after participation in the curriculum. A qualitative evaluation of the curriculum was also performed.

Results: Pretest and posttest responses showed significant improvement in residents’ knowledge about COPC and a small but significant decline in attitudes toward COPC. Residents’ reactions to the curriculum in the qualitative evaluation were both positive and negative. Residents enjoyed the group process and found it intellectually stimulating. Many reported, however, that they did not feel ownership of the project, that working through the four-step systematic COPC process was slow and cumbersome, and that they had learned only part of the COPC process. Residents consistently reported becoming more aware of the importance of discussing the focus of the project (ie, childhood discipline or domestic violence) with their patients and feeling more comfortable initiating such discussions.

Conclusions: A COPC curriculum based on required participation in a 2-year group project promoted completion of substantial projects. There were trade-offs in resident experience, including loss of continuity for individual residents. Effectively teaching COPC and engaging residents in community-oriented activities remains a challenge.

Educational Research and Methods
(Fam Med 1998;30(6):424-30.)

Residents Find Clinical Practice Guidelines Valuable as Educational and Clinical Tools
A Helwig; D Bower; M Wolff; C Guse

Background and Objectives: Information regarding clinical practice guideline (CPG) use in residency education is limited. We surveyed a regional population of family practice residents to determine use, attitudes, and curricular needs for practice guidelines.

Methods: A written survey was developed that measured residents’ exposure to, frequency of use, attitudes, access, and knowledge about use of CPGs. The survey was mailed to 114 family practice residents.

Results: The response rate was 75%. The most frequently seen guidelines were immunization schedules, cancer screening, hyperlipidemia, and hypertension management. The residents reported positive attitudes toward CPGs; 75% thought CPGs were easy to use, 80% thought they improved their efficiency, 78% thought they improved their residency education, and 75% thought they improved patient care. Barriers to effective use of practice guidelines were also identified; 20% knew where to find guidelines in their clinic, 35% had faculty modeling, and 22% knew how to evaluate the validity of a guideline. Eighty-nine percent of respondents desired instruction on CPG use and interpretation.

Conclusions: The surveyed family practice residents have similar usage rates for CPGs as the literature reports for practicing physicians, but residents report more positive attitudes. Barriers that prevent effective use of CPGs in training environments include lack of critical appraisal abilities and faculty role modeling.

Educational Research and Methods
(Fam Med 1998;30(6):431-5.)

Care of Persons With AIDS
in the Nursing Home
John Michael Heath, MD

Background and Objectives: AIDS is becoming a chronic illness for some patients whose significant accumulated functional impairments may limit community-based care. Nursing homes can provide an appropriate level of care, although reported experience caring for persons with AIDS in this setting is limited.

Methods: A retrospective case-series review was conducted in a 242-bed community teaching nursing home to describe the initial 26-month experience in providing care for patients with AIDS requiring nursing home admission.

Results: A total of 42 admissions by 32 patients with AIDS (mean age=33.5years, 81% male) involved a shorter length of stay (mean 63.1 days) and higher numbers of medications (mean=11.2), facility charges (mean $11,971/admission, $189/day), and greater clinical management complexity than usual nursing home patients. Thirteen patients were discharged, seven for rehospitalization and six into community settings, although ultimately 29 of the 32 patients died in the facility.

Conclusions: AIDS care in the nursing home presents significant, distinct challenges in complex management and terminal care prioritization.

Clinical Research and Methods
(Fam Med 1998;30(6):436-40.)

Improving Diabetes Preventive Care in a Family Practice Residency Program: A Case Study in Continuous Quality Improvement
Chester H. Fox, MD; Martin C. Mahoney, MD, PhD

Background and Objectives: The paradigm of continuous quality improvement (CQI) holds promise for application in clinical settings. This paper highlights results of a CQI project developed and implemented in a residency-based, ambulatory family medicine center for management of non-insulin-dependent diabetes mellitus.

Methods: We developed a CQI program that used several indicators of diabetes management as measures of quality care. These included dietary counseling, exercise counseling, foot care counseling, ophthalmology referral, and measurement of hemoglobin AIC and renal function.

Results: Overall, compliance with recommendations for diabetes management increased from a baseline proportion of 40% to a level of 70% at the end of 1 year. During the second year, overall compliance was maintained at this level despite the inclusion of additional performance indicators.

Conclusions: The CQI process can improve physician performance in managing patients with diabetes.

Clinical Research and Methods
(Fam Med 1998;30(6):441-5.)

The Birth of the Blended Curriculum
Bruce A. Leibert, MD

Background and Objectives: In the struggle to survive economically, our family practice residency program developed a new curriculum that incorporated elements of both the conventional rotational model and the newer longitudinal model. We also created unique elements: immersion weeks, subspecialty clinics, and Tuesday specials. Immersion weeks provide focused exposures to specialty areas. The resident brings learned skills back to the family practice clinic (FPC). Subspecialty clinics in the FPC bring specialists to the residents and to the residents’ patients for reinforcement of learned skills. Tuesday specials provide longitudinal experiences in geriatric, community, and occupational medicine. The blended curriculum has been a success with both Residency Assistance Program consultants and the Residency Review Committee reviewer. It has also increased residents’ availability to see patients in the FPC and increased FPC income.

Commentary
(Fam Med 1998;30(6):449-51.)