Background: Family practice residency program directors and faculty are frequently faced with residents who sustain a temporary illness or become disabled during residency. In addition, disabled applicants are seeking positions in medical schools and residencies. Program directors and faculty have an obligation to understand the laws that apply to disability and illness to develop fair and workable policies within their programs. This article explores the provisions of the Americans With Disabilities Act that apply to family practice residency programs and residents with illness and disability. One of the key requirements for dealing with resident illness or disability is the development of essential job functions. We present a strategy to enable individual residency programs to develop a list of essential job requirements for family practice residents. An example of essential job requirements is given.

Special Articles: The Americans With Disabilities Act
(Fam Med 1999;31(9):617-21.)

Failure to Keep Clinic Appointments: Implications for Residency Education and Productivity
Allen L. Hixon, MD; Ronald W. Chapman, MD, MPH; Jim Nuovo, MD

Background and Objectives: We conducted a study of family practice residency programs to investigate the number of deliveries performed by residents during training.

Methods: A one-page questionnaire was mailed to family practice residency program directors, requesting an estimate of the number of deliveries performed by each resident. In addition, information on residency characteristics was taken from the American Academy of Family Physicians Directory of Family Practice Residency Programs.

Results: Responses were received from 316 programs, for a response rate of 70%. Residency directors estimated that residents did a mean of 18 continuity and 24.5 obstetrics block month deliveries. On the average, residents delivered 93.9 babies in 3 years of residency. The number of continuity deliveries was related to location of the program and type of program. Total deliveries related to the presence of a competing obstetrics program, faculty who were doing their own deliveries, location of the program, and number of required months of obstetrics. On multivariate analysis, only the latter two variables predicted the number of total deliveries.

Conclusions: Family practice residents deliver an average of 94 babies in 3 years of residency training. Programs that want to increase deliveries can best do so by increasing the number of required months of training.

Residency Education
(Fam Med 1999;31(9):627-30.)

Number of Deliveries Performed During Family Practice Residency Training
Victoria E. Murrain, DO; Paul Gordon, MD; Janet Senf, PhD

Background and Objectives: We conducted a study of family practice residency programs to investigate the number of deliveries performed by residents during training. Methods: A one-page questionnaire was mailed to family practice residency program directors, requesting an estimate of the number of deliveries performed by each resident. In addition, information on residency characteristics was taken from the American Academy of Family Physicians Directory of Family Practice Residency Programs.

Methods: A one-page questionnaire was mailed to family practice residency program directors, requesting an estimate of the number of deliveries performed by each resident. In addition, information on residency characteristics was taken from the American Academy of Family Physicians Directory of Family Practice Residency Programs.

Results: Responses were received from 316 programs, for a response rate of 70%. Residency directors estimated that residents did a mean of 18 continuity and 24.5 obstetrics block month deliveries. On the average, residents delivered 93.9 babies in 3 years of residency. The number of continuity deliveries was related to location of the program and type of program. Total deliveries related to the presence of a competing obstetrics program, faculty who were doing their own deliveries, location of the program, and number of required months of obstetrics. On multivariate analysis, only the latter two variables predicted the number of total deliveries.

Conclusions: Family practice residents deliver an average of 94 babies in 3 years of residency training. Programs that want to increase deliveries can best do so by increasing the number of required months of training.

Residency Education
(Fam Med 1999;31(9):631-4.)

Exploring Instructional Quality Indicators in Ambulatory Medical Settings: An Ethnographic Approach
Luis E. Zayas, MA; Paul A. James, MD; Judy A. Shipengrover, PhD; Diane G. Schwartz, MLS; Jason W. Osborne, PhD; Robin P. Graham, PhD, MPH

Background and Objectives: As medical education moves to community settings, the quality of learning is influenced by differences in the practice environment, organization, resources, patient case mix, and demographics. This ethnographic study identified experiences and processes that influence student learning in community-based practice settings.

Methods: Trained field researchers conducted participant observation in eight community teaching sites. Data were analyzed using a qualitative, grounded theory approach.

Results: Three dominant themes emerged: 1) the preceptor’s role in situating learning opportunities, 2) the learner’s role in transforming experience into learning, and 3) the practice organization as a classroom setting. The findings highlight the importance of exploiting learning opportunities and the contributions of other medical staff and patients in facilitating unique learning experiences.

Conclusions: This research suggests the need to move beyond the typical student ratings of teacher effectiveness to consider and assess additional important factors and processes that affect instructional quality.

Medical Student Education
(Fam Med 1999;31(9):635-40.)

Choosing a Specialty During a Generalist Initiative: A Focus Group Study
Anton J. Kuzel, MD, MHPE; Shelly S. Moore, MA

Background and Objectives: Virginia Commonwealth University (VCU) (as part of a three-school consortium) was 1 of 12 sites awarded a Robert Wood Johnson Generalist Physician Initiative (RWJ-GPI) grant. Given the goals of this initiative—to promote a balanced output of generalists and specialists—program planners wanted to understand how medical students made career decisions in the context of this curriculum change and the larger social environment.

Methods: Seven focus groups (average size: six members each) of second-year and fourth-year students were recruited. Groups were homogenous with respect to subspecialty or primary care orientation and career trajectory. An experienced moderator conducted all groups. The discussions were taped and transcribed. Analysis proceeded concurrently with data gathering, using a template style and with assistance from the NUD*IST® software program.

Results: Students from all groups hoped for control of their practice, intellectual challenge, rewarding relationships with their patients and their own families, and fair compensation for effort. They worried about their future prospects, and specialty-oriented students felt that the emphasis on primary care production was being forced on the school. All groups saw managed care as doing more harm than good for patients, and all wished for improved career counseling.

Conclusions: The RWJ-GPI at VCU became a lightning rod for student worry and resentment at being forced into primary care specialties. The backlash phenomenon was seen at other US medical schools and is one of the postulated reasons for a decline in US student numbers matching in family practice, internal medicine, and internal medicine-pediatrics. Medical school faculty should respond with constructive, pro-student policies and programs.

Medical Student Education
Fam Med 1999;31(9):641-6.)

Hypertension, Cardiovascular Disease, and Health Care Dilemmas in the Philadelphia Vietnamese Community
Trang M. Pham, MD, MS; Michael P. Rosenthal, MD; James J. Diamond, PhD

Background and Objectives: Prior studies have shown low awareness of hypertension and cardiovascular disease and low health care utilization in the US Vietnamese community. This study assessed awareness and understanding of these chronic conditions, health care barriers, and cultural beliefs in the Philadelphia Vietnamese community.

Methods: This qualitative study analyzed data collected from focus groups, family interviews, and individual interviews of community members and health care providers during 1996 and 1997.

Results: Awareness of hypertension was higher than expected but low for heart disease. Understanding of the cause and primary prevention of these illnesses was low, as was health care utilization. Major barriers to receiving health care included problems with language, medical insurance, and transportation. Desired resources were interpreter services, increased medical insurance, translated educational materials, health education classes, and community health fairs. The community widely held the belief that Western medicine is “stronger, faster, and curative” while folk medicine is “weaker, slower, but preventive.”

Conclusions: The Vietnamese community appreciates the importance of hypertension and cardiovascular disease and believes that traditional, Western medicine is necessary for care but perceives significant barriers. Providing needed services and specific intervention programs could improve access and understanding, as well as enable health promotion, disease prevention, and appropriate care.

Clinical Research and Methods
(Fam Med 1999;31(9):647-51.)

Lessons Learned From ACGME
John W. Saultz, MD; C. Earl Hill, MD

Background and Objectives: The year 1998 brought to a close our 6 years of service as representatives to the Accreditation Council for Graduate Medical Education. These have been challenging times for graduate medical education (GME), and our time on the council has been an educational experience of the first order. This paper describes our experiences and summarizes the issues we believe lie ahead for GME, particularly for family practice residency programs.

Commentary
(Fam Med 1999;31(9):652-5.)