Predictors of Physician Nursing Home Practice: Does What We Do in Residency Training Make a Difference?
John D. Gazewood, MD, MSPH; David R. Mehr, MD, MS

Background and Objectives: The number of physicians who care for nursing home patients is inadequate. This study determined predictors of current nursing home practice, including whether making nursing home rounds with an attending physician during residency is a predictor of subsequent nursing home practice.

Methods: We used a cross-sectional survey to study 170 family physicians in private or academic practice in a large, university-based Midwestern family practice residency program.

Results: The response rate was 86%. Fifty-five percent of respondents had an active nursing home practice. Rounding in a nursing home with an attending during residency had no relation to current nursing home practice. In comparison to physicians without an active nursing home practice, physicians with an active nursing home practice were more likely to reside in a smaller community, have a hospital practice (60.5% versus 39.5%), see more outpatients per week (105 versus 78), and work more hours per week (57 versus 49). In a logistic regression model, decreasing community size, number of hours worked per week, and having an active hospital practice were associated with active nursing home practice.

Conclusions: Factors other than educational experience have an effect on physician nursing home practice.

(Fam Med 2000;32(8):551-5.)

The Reflecting Team: An Innovative Approach for Teaching Clinical Skills to Family Practice Residents
Patricia Lebensohn-Chialvo, MD; Marjorie Crago, PhD; Catherine M. Shisslak, PhD

Background and Objectives: This paper provides a description and evaluation of the reflecting team approach as a teaching method for family practice residents. We have used the reflecting team approach in our longitudinal behavioral health program for 6 years. Our purpose in using this approach is to 1) teach listening and interviewing skills, 2) teach systems-oriented psychosocial interventions, and 3) provide behavioral health consultations for patients. Methods: A five-item, self-administered, open-ended questionnaire evaluating the reflecting team approach was administered to a sample of family practice residents.

Results: Completed questionnaires were received from 18 of the 22 family practice residents participating in the longitudinal behavioral health program (a response rate of 82%). Responses to the questionnaire items indicated that the residents understood the purpose of the reflecting team approach and felt that they had acquired a variety of clinical skills from the approach, including listening and interviewing skills, positive reframing of patients’ problems, how to give positive feedback to promote behavioral change, and increased knowledge of psychosocial assessment procedures and treatment methods.

Conclusions: The residents’ responses to the questionnaire items indicated that they perceived the reflecting team approach to be a practical and useful method for learning a variety of clinical skills.

(Fam Med 2000;32(8):556-60.)

Background and Objectives: Clotrimazole/betamethasone diproprionate contains a fluorinated, high-potency topical corticosteroid and is the most frequently prescribed topical agent in the United States. Family physicians are more likely than pediatricians and dermatologists to use this product when faced with a common fungal infection. To better understand the settings in which US family physicians recommend the use of clotrimazole/betamethasone diproprionate, we determined the diagnoses and characteristics of patients for whom family physicians prescribe this drug.

Methods: Data from the National Ambulatory Medical Care Survey were used to determine the demographic characteristics of patients who were given a prescription for clotrimazole/betamethasone diproprionate, the diagnoses of patients treated with the drug, and the potency of other topical corticosteroids by family physicians. Wholesale costs of drugs were used to estimate potential drug cost savings obtainable by switching to specific monotherapy agents.

Results: Clotrimazole/betamethasone diproprionate was prescribed at 3.1% of visits to family physicians but at only .6% of visits to dermatologists for either inflammatory or fungal/candidal conditions. Family physicians frequently prescribed clotrimazole/betamethasone diproprionate to children under age 5 and for use on genital skin disorders. Dermatologists rarely used clotrimazole/betamethasone diproprionate in these settings.

Conclusions: The frequent use by family physicians of clotrimazole/betamethasone diproprionate in high-risk settings is of concern. Use of alternative agents with anti-inflammatory and antifungal properties without the risks associated with the use of high-potency topical corticosteroids may be the most practical approach to replacing use of clotrimazole/betamethasone diproprionate.

(Fam Med 2000;32(8):561-5.)

New World Views: Preparing Physicians in Training for Global Health Work
Cynthia Haq, MD; Deborah Rothenberg, MD; Craig Gjerde, PhD; James Bobula, PhD; Calvin Wilson, MD; Lynn Bickley, MD; Alberto Cardelle, PhD, MPH; Abraham Joseph, MBBS

Background and Objectives: To determine the impact of international health experiences on physicians in training, we studied 60 US medical students who participated in an International Health Fellowship Program (IHFP).

Methods: In 1995 and 1996, US medical students were selected to participate in the IHFP, which included training at three US medical schools and at seven medical schools in developing countries. The program included a 2-week preparatory course at a US school and a 6- to 8-week field experience. Evaluative data were collected prior to the course, after the course, after the field experience, and 1–2 years later.

Results: A total of 60 students were selected from 145 applicants. At the end of the fellowship, a majority of participants noted that the exposure affected them in the following ways: changed world views; increased cultural sensitivity; enhanced community, social, and public health awareness; enhanced clinical and communication skills; more appropriate resource utilization; changes in career plans; and a greater understanding of the challenges of working in areas with scarce resources. After the international field experience, students more strongly agreed with the importance of oral rehydration, communication skills, and patient education. According to student self-assessments, the IHFP significantly improved core medical skills. Ninety-six percent of participants recommended international health experiences for other students.

Conclusions: This study of IHFP fellows demonstrates multiple significant impacts of international health experiences on US medical students in training. The knowledge, attitudes, and skills gained through international health experiences are important for medical practice in the United States and abroad. Given the high interest of medical students in international health and the potential for positive educational impacts, medical schools should increase the availability of high-quality international experiences.

(Fam Med 2000;32(8):566-72.)