Background and Objectives: This study compared the effectiveness of two booster strategies designed to improve retention of skills and knowledge in neonatal resuscitation by family practice residents.

Methods: Residents were randomly allocated to one of three groups: video, hands on, or control. Residents in the two experimental groups received a “booster” 3–5 months after the Neonatal Resuscitation Program (NRP) course. All participants completed the follow-up test 6–8 months after taking the course. The main outcome measures consisted of the NRP written examination and the performance checklists.

Results: A total of 44 residents completed the study (video, n=13; hands- on, n=14; control, n=17). Overall, participants had significantly lower scores at follow-up than at baseline, indicating deterioration in both neonatal skills and knowledge. Residents in the hands-on booster group made significantly fewer errors across all five checklists in life-supporting but not in lifesaving scores than those allocated to the control and video groups.

Conclusions: The beneficial effect of mannequin practice or video boosters on skills and knowledge retention was less than what had been anticipated, and no benefit could be demonstrated in comparison to the control group. Deteriorating knowledge and skills remain a major concern, since boostering by hands-on or video at 3–5 months do not seem to have an impact on the retention of knowledge or lifesaving skills.

Educational Research and Methods (Fam Med 1998;30(10):705-11.)

Enhancing the Family Medicine Curriculum in Deliveries and Emergency Medicine as a Way of Developing a Rural Teaching Site
Wm. MacMillan Rodney, MD; Loren A. Crown, MD; Ricardo Hahn, MD; John Martin, MD

Background: The urban family practice residencies of Memphis were not providing sufficient training or encouragement to young physicians for practice in rural communities.

Methods: In 1990, the Department of Family Medicine, in partnership with the State of Tennessee Health Access Act and the Baptist Health Care System, developed a teaching practice in a rural county of western Tennessee. The family practice curriculum included special skills in advanced women’s health care and emergency medicine so that uniformly trained physicians could provide around-the-clock coverage in the hospital, including the delivery of babies and first-hour emergency care.

Results: After 7 years, the group now includes six full-time, board-certified, OB-capable family physicians. In addition, faculty members from the department’s urban program in Memphis are required to contribute a “mini locum tenens” of 2–3 days of rural coverage per month. Since 1992, the practice has provided care for more than 54,000 continuity office visits, 81,000 emergency department visits, more than 3,500 hospital admissions, and 621 obstetrical deliveries. Since 1994, residents have been assigned to the site full time, with growth to 12 (4-4-4) residents assigned to this location as of 1997. Several graduates from the initial group of residents have remained in the community after graduation, and three others have established practices in rural areas. Most recently, control of the practice is being transferred from the family medicine department to the university’s corporate group practice. This may result in fundamental changes in the practice’s operation.

Conclusions: The approach described in this report may be useful for the expansion of urban departments of family medicine into rural and underserved communities.

Educational Research and Methods
(Fam Med 1998;30(9):712-9.)

Implementing Problem-based Learning in a Family Medicine Clerkship
Evelyn T. Washington, MD; James W. Tysinger, PhD; Laura M. Snell, MPH; Lawrence R. Palmer, MD, MPH

Background and Objectives: Problem-based learning (PBL) has been implemented in the curriculum of many medical schools, but limited information is available about the outcome of this learning technique. The educational intervention presented in this paper implemented a PBL learning component in our third-year family medicine clerkship and measured the outcomes of this curricular change.

Methods: One third of the curricular time devoted to didactic teaching in our family medicine clerkship was replaced with PBL activities. Simulated cases were developed and presented to students who, with the aid of faculty facilitators, studied the cases, gathered information about the cases, and developed diagnostic and management plans for the cases. The outcome of the intervention was measured by a) comparing students’ scores on the National Board of Medical Examiners (NBME) family medicine clerkship examination to scores achieved by students in the year before PBL was introduced and b) students’ evaluations of the relevance and success of PBL in the clerkship curriculum.

Results: Students’ NBME clerkship examination scores increased from a mean of 66 the year before PBL began to 73 after PBL was implemented. More than 80% of students reported that PBL was a good way to learn family medicine, and 85% reported that the PBL technique provided sufficient information to formulate learning issues.

Conclusions: PBL can be introduced into a third-year family medicine clerkship curriculum with general acceptance by students. Students rated the technique highly, and their examination scores improved.

Educational Research and Methods
(Fam Med 1998;30(10):720-6.)

Do We Practice What We Teach About Childhood Immunization in New Jersey?
Catherine M. Sharkness, MD, MS; Barbara D. Goun, PhD; Lloyd A. Davis, MD; Lakeisha E. Sykes

Background and Objectives: Although childhood immunization is a benchmark for preventive service delivery in family practices, no data have been reported on childhood immunization in New Jersey family practice residencies. This study assesses immunization coverage among 2-year-olds in nine residencies and evaluates childhood immunization knowledge and barriers in 10 residency programs.

Methods: We performed a retrospective review of immunization records of 2-year-olds, using the Centers for Disease Control’s Clinic Assessment Software Application, and analyzed a survey of knowledge and barriers to immunization completed by residents, nurses, and faculty.

Results: Among 726 children with four or more office visits, the mean percent of children immunized with the combination of four diphtheria-tetanus-pertussis, three polio, and one measles-mumps-rubella was 53% (range 31%–69%). The age-appropriate immunization rate was highest at 3 months (78%) and lowest at 16 months (29%). Among the 294 survey respondents, the mean knowledge score was 75% overall and 82% for faculty, 77% for nurses, and 71% for residents. There was moderate to good correlation of audit levels with knowledge, with 49% of the variation in immunization coverage explained by variation in knowledge. Lack of immunization records was reported by 47% as the most important office-related barrier.

Conclusions: Immunization rates of 2-year-olds in nine New Jersey family practice residencies are below Healthy People 2000 goals. Low immunization rates in residency programs may improve with increased knowledge, an area for future study. Research into removing immunization-related barriers is also needed.

Educational Research and Methods
(Fam Med 1998;30(10):727-32.)

Prescription Medication Use in Older Americans: A National Report Card on Prescribing
Saif S. Rathore; Shilpa S. Mehta, PharmD; William L. Boyko, Jr, PharmD; Kevin A. Schulman, MD

Background and Objectives: Due to their high prevalence of disease, older Americans receive more prescription medication than any other age group. We evaluated prescription medication use in patients age 50 or older; categorized and reported medication use by age group, drug class, and therapeutic class; and examined differences in prescribing patterns for older patients.

Methods: All prescription medications reported in the 1995 National Ambulatory Medical Care Survey, a nationally representative sample of ambulatory care visits in the United States for patients age 50 and older (n=16,289), were evaluated in a cross-sectional analysis. We evaluated the number of prescription medications reported for each patient visit and ranked use of drug and therapeutic classes.

Results: Most patients seeing physicians (61%) had a prescription for at least one medication, ranging from a mean of 1.27 medications in patients ages 50–64 to 1.58 in patients over 85. Calcium channel blockers and angiotensin-converting enzyme inhibitors were prescribed more than beta blockers in all patients. Data also indicated a significant decrease in estrogen/progestin and antidepressant medication use in older patients.

Conclusions: Our findings indicate prescribing patterns inconsistent with national guidelines and decreased medication use, suggesting underprescription. Active intervention may be needed to improve the pharmacological treatment of older patients.

Clinical Research and Methods
(Fam Med 1998;30(10):733-9.)