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ABSTRACTS
Special Article
Resource-based Relative
Value Units: A Primer for Academic Family Physicians
Sarah E. Johnson, MD; Warren P. Newton, MD, MPH
The Resource-based Relative Value Scale (RBRVS) is the
prevailing model used to reimburse physician services
today. Based on empirical research, relative value units
(RVUs) quantify the relative work, practice expense,
and malpractice costs for specific physician services
to appropriately establish payment. The fee schedule,
implemented by the Health Care Financing Administration
in 1992, dramatically affected physician reimbursement,
with the goal of correcting disparities across disciplines.
In the first 6 years, Medicare payments to family physicians
increased by 36%, while payments to specialists decreased
by as much as 18%. Recent changes include new practice
expense estimates and adjustment of payment based on
facility type. The impact of RVUs is even more widespread
as many private payers use the fee schedule to set payment
rates and as RVUs become the yardstick for physician
productivity measures. Despite the initial successes,
the ability of RVUs to capture the work done by primary
care providers is still limited. Primary care services
today are not as easily quantified as surgical procedures,
and coding limitations hinder documentation of services.
Rapid changes in health care make comparisons to work
done 2 decades ago difficult. Understanding the strengths
and limitations of RVUs as they apply to family physicians
is fundamental to safeguarding the role of primary care.
(Fam Med 2002;34(3):172-6.)
Residency
Education
The State of Community Medicine Training in Family
Practice Residency Programs
Marcus Plescia, MD, MPH; Joseph C. Konen, MD, MSPH;
Amy Lincourt, PhD
Objectives: This paper describes the state and nature
of community medicine training in family practice residency
programs. Methods: A random sample of 224 family practice
residency programs was surveyed about the perceived
value of community medicine in their residency, the
teaching modalities they use, the extent to which their
training provides competency in four defined dimensions
of community medicine, and which program characteristics
and curricula were predictive of higher perceived competency.
Results: The participation rate of our survey was 72%.
Respondents ranked professional interest, institutional
support, and departmental support highly. Less than
half the programs provide instruction in community-
oriented primary care (COPC), and less than half rate
their department’s involvement in the community highly.
Most programs report that their training provides at
least a moderate level of competency in four defined
dimensions of community medicine. Curricular methods
that are predictive of perceived competency include
health department clinical experiences, home visits,
cultural sensitivity training, participation in a longitudinal
project, meetings with community leaders, and instruction
in COPC. Conclusions: Community medicine is valued in
residency curricula, but there is limited uniformity
in curricular content and methods. Active and structured
education modalities might be more likely to result
in competency in community medicine.
(Fam Med 2002;34(3):177-82.)
Prevalence
of Community-oriented Primary Care Knowledge, Training,
and Practice
Shirley K. Longlett, MS, LCPC; Debra M. Phillips,
MD; Robert M. Wesley, MA
Background and Objectives: Recent recommendations
requiring resident training in community-oriented primary
care (COPC) indicate a continued interest among family
medicine educators. This study examines COPC-related
aspects of training and practice and whether or not
respondents report COPC knowledge. The study also compares
residency program and physician responses. Methods:
A total of 400 randomly selected practicing physicians
and 470 residency directors were asked about COPC curricular
and practice experiences. Physicians were asked if they
practice COPC. Programs were asked if they taught COPC.
Both were asked if they were knowledgeable about COPC.
Results: Response rates for practicing physicians and
programs were 58.4% and 71.8%, respectively; 38.8% of
programs teach COPC, and 6.7% of physicians reported
that they practice COPC. Sixty-seven percent of programs
and 19% of physicians reported COPC knowledge. Programs
with knowledge of COPC conducted more COPCrelated activities
than those without such knowledge. This relationship
was not seen among practicing physicians. Conclusions:
Aspects of COPC exist in training and in practice environments.
Knowledge about COPC is associated with differences
in programs’ COPC activities but not in the COPC activities
of practicing physicians. Programs and physicians differ
in COPC implementation in training and practice.
(Fam Med 2002;34(3):183-9.)
Working
With Impaired Residents: Trials, Tribulations, and Successes
Robin O. Winter, MD, MMM; Bruce Birnberg, MSW
Impairment of physicians’ ability to practice medicine
safely and effectively is relatively common. Chemical
dependency, the leading cause of physician impairment,
has a lifetime prevalence of approximately 10%–15% among
physicians. Statistics from physician health programs
indicate that family physicians are overrepresented
among impaired physicians. It is therefore important
for family practice residencies to monitor for and deal
with physician impairment. Over the past 11 years, we
have worked with eight impaired residents: five with
chemical dependency, two with cognitive impairment,
and one with an affective disorder. Seven of the eight
residents are currently practicing medicine, six in
family practice. Based on our experience and the literature,
we have developed an algorithm that includes the recognition,
intervention, and aftercare of impaired residents. The
long-term success of the majority of impaired residents
with whom we have worked suggests that the trials and
tribulations of working with this potentially difficult
group of residents are well worth the effort.
(Fam Med 2002;34(3):190-6.)
Medical
Student Education
Self-directed Learning: Looking at Outcomes With
Medical Students
Gurjeet S. Shokar, MD; Navkiran K. Shokar, MD; Cecilia
M. Romero, MD; Robert J. Bulik, PhD
Background and Objectives: Self-directed learning (SDL)
skills are thought to be associated with lifelong learning.
This study assessed the degree of readiness for SDL
in third-year medical students who participated in a
problem-based learning (PBL) curriculum during the first
2 years of medical school. Methods: A total of 182 third-year
medical students at the University of Texas Medical
Branch at Galveston were given the Self-directed Learning
Readiness Scale (SDLRS). Results: The observed mean
(235.81 [range 183–284]) for the combined group was
significantly higher than the mean reported for general
adult learners (214), though slightly lower than scores
reported in studies of other medical students and professionals.
Ratings of students by clinical preceptors correlated
with SDLRS scores. Conclusions: Students in our integrated
medical curriculum had scores on the SDLRS that correlated
with clinical performance and probably represented a
readiness for SDL. (Fam Med 2002;34(3):197-200.)
Clinical
Research and Methods
Use
of a Peripheral Dexa Measurement for Osteoporosis Screening
Julienne K. Kirk, PharmD; Mindy Nichols, RD; John
G. Spangler, MD
Background and Objectives: Osteoporosis is a substantial
cause of morbidity and mortality in the United States.
While screening for this disease is important, few studies
have evaluated the role of an osteoporosis screening
device in a family practice setting. This study evaluated
the influence of a peripheral- dexa (p-dexa) heel bone
mineral density (BMD) measurement and a patient education
program on changes in pharmacologic treatment for suspected
osteopenia or osteoporosis by primary care physicians
over a 1-year follow-up. Methods: Using a computerized
database (ages 50 to 75 years), 1,927 women were identified.
An invitation was mailed to register for a screening
to have a p-dexa heel BMD scan done and to attend an
osteoporosis prevention presentation. Medication history,
age, height, weight, and risk factors for osteoporosis
were collected. A follow-up chart review was carried
out on women who were found to have heel BMD T-scores
of <-.6 (suggested by the World Health Organization).
Date of menopause onset, pharmacotherapy for osteoporosis,
calcium, vitamin D, and physician intervention were
assessed. Results: There were 292 women (15.2%) who
self registered, obtained BMD testing, and attended
an educational program. Of these women, 87 (30%) had
at least one risk factor for osteoporosis, in addition
to menopause. Mean BMD was .489 ± .113 gm/cm2 (normal
>.42 gm/cm2). A post-screening chart review was completed
in 102 women (36.6%) at greatest risk for osteoporosis
based on a T-score <-.6. Following the intervention,
26 women were started on antiresorptive therapy (primarily
estrogen), and three additional women had a second antiresorptive
agent added to estrogen. Conclusions: P-dexa heel BMD
has utility for screening patients at risk for osteoporosis.
However, only 15% of invited women attended the screenings,
and pharmacotherapy treatment did not significantly
change after screening in the majority of women at risk
for osteoporosis, based on p-dexa screening.
(Fam Med 2002;34(3):201-5.)
Use
of Alternative Medicine by Patients in a Rural Family
Practice Clinic
Winfred F.B. del Mundo, MD; William C. Shepherd,
MD; Thomas D. Marose
Background and Objectives: There has been an increasing
awareness of the use of alternative medicine and its
effect on health care in the United States. However,
no previous study has looked at its use among primary
care patients in a rural setting. We conducted this
study to determine the patterns of use of alternative
medicine in this population. Methods: A questionnaire
was distributed to 750 adult patients in a family practice
clinic in northern Pennsylvania. Results: Our response
rate was 88% (664/ 750). Forty-seven percent of patients
reported using at least one form of alternative medicine
during the past year. The most-common types used were
chiropractic (used by 17.2% of respondents), relaxation
techniques (16.9%), herbal medicine (16.9%), and massage
(14.2%). The patients surveyed used alternative medicine
more for its benefits than because of dissatisfaction
with conventional medicine. Only 51% of patients told
their physician about their use of alternative medicine.
Conclusions: A significant number of rural family practice
patients are using alternative medicine. To better address
their patients’ needs, primary care physicians should
routinely ask patients about their use of alternative
medicine and advise them accordingly.
(Fam Med 2002;34(3):206-12.)
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