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ABSTRACTS
Special Article
Applications of Narrative Theory and Therapy to the
Practice of Family Medicine
J Shapiro; V Ross
This article presents
narrative theory and therapy as an approach with significant
potential for providing family physicians with additional
tools to assist them in dealing with difficult clinician-patient
encounters. We first define narrative therapy, then
briefly describe its theoretical assumptions in relation
to psychosocial concepts already familiar to family
physicians. Important aspects of narrative therapy are
examined, including the unique role of questioning in
the narrative process; understanding and helping patients
change their problem-saturated stories; renaming and
externalizing the patient problem; and the use of rituals,
documents, and audience in recognizing and reinforcing
patient change. The article concludes with thoughts
about how narrative approaches can contribute to more-healing
doctor-patient relationships. (Fam Med 2002;34(2):96-100.)
Residency
Education
Orienting Interns to Being
Second-year Residents
JH Merenstein; P Preisach
Background: Although
orientation to the first year of residency is universal
in family practice residencies, there is no published
information on preparing first-year residents to become
upper-level residents, an almost equally dramatic change.
Methods: We conducted a national survey of all 484 family
practice residency directors by e-mail and regular mail.
Results: The total response was 365 (75.4%). Slightly
more than half (185) of the residencies had a formal
program to prepare for the transition to second-year
resident. Both faculty and upper-level residents taught
or exchanged information using multiple methods of teaching
but mostly lectures and seminars. Topics included practical
issues related particularly to new responsibilities,
teaching and supervising skills, and the general topics
of leadership and communication. An important minority
objected to these orientations, expressing concern that
they distracted from the ultimate goal of training competent
practitioners. Conclusions: Orientation to the second
year of residency is common, brief, and specific. No
evaluation of the value of these programs exists. (Fam
Med 2002;34(2):101-3.)
Family
Practice
Residents’ Awareness of Medical Care Costs in British
Columbia
GM Allan; G Innes
Background and Objectives:
Health economics continues to be an important issue,
and past studies in the United States and Europe have
found that physicians and physicians in training have
a limited understanding of medical care costs. No medical
care cost-awareness studies have been done in Canada.
In this study, the costs of 46 commonly used diagnostic
tests and therapeutics were determined, and family practice
residents’ awareness of these costs was assessed. Methods:
Ninety-seven first- and second-year residents of the
University of British Columbia Family Practice Program
were surveyed using the modified Dillman Total Design
Method. Resident cost estimations were considered correct
if within 25% or 50% of actual costs, and awareness
was correlated with training location, gender, residency
year, and importance ratings for ordering behavior.
Degree of error was assessed by calculating median percent
errors and confidence intervals for each therapeutic
and diagnostic test. Results: Costs were determined
from the British Columbia Medical Association Guide
to Fees, British Columbia Centre for Disease Control,
hospital finance departments, and pharmaceutical wholesalers.
A total of 82 (85%) residents completed the survey,
but 11 were only partially completed. Few residents
could estimate the cost of diagnostic tests or therapeutics
to within 25% of the true cost, and the estimations
were highly variable. Residents underestimated the cost
of expensive drugs and overestimated the cost of inexpensive
drugs. There was no relationship between cost awareness
and training location, gender, residency year, or residents
rating cost as important in ordering behaviour. Conclusion:
Resident physicians in British Columbia, Canada have
limited awareness of medical care costs. (Fam Med 2002;34(2):104-9.)
Medical
Student Education
Family Medicine Clerkship Web Sites: The State of the
Art
C Reznich; J-Y Shin; T Korin; T Vincent
Background and Objectives:
The use of on-line syllabi to acquire information about
a course, clerkship, or rotation is growing. This study
investigated the number of existing family medicine
clerkship Web sites with syllabi and determined their
completeness and usability. Methods: In sping 1999,
all schools with third-year family medicine clerkship
Web sites were identified (n=71) using Association of
American Medical Colleges and American Academy of Family
Physicians clerkship directories to identify required
family medicine clerkships, followed by a Web search
to identify any associated Web sites. A checklist with
11 content and 5 technical categories was developed
and pilot tested. All sites were evaluated by at least
two investigators. Two identifiable checklist characteristics
were required to be present for a site to be identified
as an on-line syllabus and included in the study. Results:
Of the 71 sites initially identified, 40 were included
in the study, 22 were excluded, and 9 required further
review by an additional evaluator. A total of 44 sites
were included in the study. The most common content
features identified were instructor information, goals,
overview, and requirements. Less-common features included
objectives, learning resources, schedule, and grading
policy. Conclusions: A minority of family medicine clerkships
have on-line syllabi. Most sites have basic information,
but other relevant clerkship information is absent.
New and revised family medicine clerkship on-line syllabus
development would benefit from using the checklist to
guide the creation of instructionally sound educational
resources. (Fam Med 2002;34(2):110-3.)
Clinical
Research and Methods
Physician Attitudes and the Use of Office-based Activities
for Tobacco Control HE McIlvain; EL Backer; BF Crabtree;
N Lacy
Objectives: This study
explored family physicians’ attitudes about smoking
cessation counseling—its importance, their confidence
in their ability to counsel, outcome expectations of
counseling, perception of their influence on patient
behavior, types of counseling skills used, and the extent
to which office-based activities are used to support
their counseling. Methods: A cross-sectional design
using qualitative and quantitative analyses was used.
Data, including information from participant observation
of the environment, medical chart reviews, and in-depth
interviews, were collected from 89 physicians, drawn
randomly from a list of family physicians in Nebraska.
Results: All physicians felt that counseling was important,
and most were confident with their ability to provide
cessation counseling. Only one third of physicians had
positive expectations regarding the outcome of this
counseling or of their influence on patient behavior
in general. The counseling skills most likely to be
used were giving advice to quit, prescriptions for pharmaceutical
aids, and discussing barriers and resources. Office-based
strategies to support physician counseling were seldom
used. Conclusions: Physician attitudes and tobacco-control
activities present a complex picture of low expectations,
little office support, and limited counseling skills
combined with a strong belief in the professional responsibility
to counsel. Motivation to increase skills or implement
supportive systems could be expected to be low. (Fam
Med 2002;34(2):114-9.)
Prenatal
Alcohol Intake in a Rural, Caucasian Clinic
MJ Hayes; E Brown; PA Hofmaster; AA Davare; KG Parker;
JA Raczek
Background
and Objectives: This study examined prior use and psychosocial
factors associated with alcohol and/or drug use in pregnant
women from a predominantly Caucasian, rural clinic in
northeastern Maine. Methods: We conducted archival record
reviews of 217 pregnant women who delivered at the Family
Practice Clinic of Eastern Maine Medical Center. As
part of the standard initial prenatal visit during the
first trimester, a nurse practitioner interviewed and
collected data from pregnant women concerning pre-pregnancy
and current-pregnancy use of alcohol, tobacco, and other
drugs. Data were available for 212 subjects. Results:
The reported prevalence of pre-pregnancy alcohol abuse
in this sample was 25%. Women in this cohort reported
a significant decrease in tobacco and alcohol use following
pregnancy awareness. However, pre-pregnancy alcohol
intake levels and years of alcohol use were associated
with alcohol intake during pregnancy. Other markers
of maternal alcohol intake during pregnancy included
tobacco use patterns and history of drug use. Family
history of alcohol problems and drug use were associated
with maternal substance use history and use by the father
of the baby. Levels of maternal alcohol use during the
current pregnancy were negatively associated with an
alcohol problem in the father of the baby. Conclusions:
Alcohol and other substance use were relatively common
in our sample of rural Caucasian women in Maine. Several
risk factors can be identified, and awareness of these
risk factors may assist physicians in the diagnosis
of substance abuse among pregnant women. (Fam Med 2002;34(2):120-5.)
Faculty
Development
A Qualitative Assessment
of One Cohort From the University of North Carolina
Family Medicine Faculty Development Fellowship
SE Woods
Objectives: This project
qualitatively assessed the critical components and global
impacts for one cohort from the part-time faculty development
fellowship at the University of North Carolina at Chapel
Hill. Methods: Sixteen individual qualitative in-person
interviews were conducted on one complete cohort of
faculty development fellows. Results: The data aggregates
into four areas of influence. The first two are the
critical components of the fellowship: the conditions
and the curriculum. The other two are the impacts of
the fellowship: the fellows’ clarity of career vision
and confidence. Conclusions: Graduates reported that
their fellowship vitalized them to pursue their ideal
position in academic family medicine. (Fam Med 2002;34(2):126-31.)
Research Series Geography and Geographic Information
Systems in Family Medicine Research ML Parchman; RL
Ferrer; S Blanchard Understanding spatial relationships
between determinants and outcomes of health care is
important as the concept of population-based health
care gains acceptance. A wide range of tools for understanding
these spatial relationships is available to the family
medicine researcher through the use of Geographic Information
Systems (GIS). The power of GIS lies in its ability
to display the spatial distribution of a health-related
predictor or outcome. These maps can then be used to
either generate or test hypotheses that would not have
otherwise occurred to the investigator without visualizing
the spatial relationships. The type of GIS application
used is dependent on the type of data the researcher
has and the research question. The three most common
types of data are point or event data, lattice data,
and geostatistical data. Point or event data can be
displayed using a technique known as geocoding. Lattice
data is most commonly displayed as shaded or colored
areas where the shading represents rates or counts.
Geostatistical data provides counts or numbers at a
given location. The analytic techniques used for analyzing
spatial data depend on the type of data. Maps tell powerful
stories and display relationships that may not be obvious
using other techniques. (Fam Med 2002;34(2):132-7.)
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