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Background and Objectives: Our objectives were to provide an update on the status of selection by medical students of family medicine as a specialty, to summarize what is known about influences on this specialty choice, and to propose a research agenda for the future., Methods: Data from the National Resident Matching Program and the American Academy of Family Physicians residency database were obtained. Past reviews of research on family medicine specialty selection were summarized, and recent research was reviewed. Gaps in the knowledge base and common research design weaknesses were listed., Results: As a result of our analysis, a set of 12 research questions are posed and a set of 11 study design recommendations made., Conclusions: Family medicine specialty choice research must be planned and conducted with the most robust methodology possible, building on past research, to produce results that can assist in formulating effective policy.

Background and Objectives: There has been declining interest by US medical students in the specialty of family medicine. Simultaneously, new data suggest that the length of training may be related to the decline in student interest. The new data have created a national debate over the appropriate length of training for family physicians. The Future of Family Medicine Report recommends conducting experiments with 4-year residency training programs., Methods: Since 1999--2000, the University of Arizona Family Medicine Residency Program has offered three fourth-year options: a fourth-year fellowship in sports medicine, an integrated third- and fourth-year experience in complementary and alternative medicine, and an option for a master's in public health degree. Data on applications to the residency program have been monitored to measure the effect of these options on the applicant pool., Results: National Resident Matching Program statistics, and the interest in the program expressed by US graduates, have improved for the University of Arizona program during a time when national interest in family medicine has continued to decline., Discussion: While cause and effect cannot be proven, offering an additional year of training did not decrease interest in the University of Arizona program and may have increased interest. Experiments with 4-year training programs are not possible in all programs because graduate medical education funding only covers the 3 years needed to complete the requirements for specialty certification.

Background and Objectives: This study investigated factors related to declining interest in family medicine by US medical school graduates., Methods: A questionnaire was sent to all physicians who graduated from 24 medical schools in 1997-1999, and who entered a family medicine residency, and a randomly selected equal number of graduates from the same years who entered other primary care specialties. Between 1997 and 1999, 12 of these schools had increases and 12 had decreases in the proportion of graduates choosing family medicine residencies., Results: Between 1997 and 1999, at schools with increasing proportions of graduates choosing family medicine, there were significant increases in the proportion of graduates who (1). had entered medical school with a specialty preference of family medicine, (2). spent their required family medicine clerkship at two or more sites, (3). ranked the competence of family medicine faculty highly, (4). reported the faculty member they most wanted to be like was a family physician, and (5). experienced clinical rotations in both family medicine and primary care. At schools with declines in the proportion of graduates choosing family medicine, there were significant declines in the proportion of graduates who (1). ranked the competence of family medicine faculty highly, (2). stated that they were encouraged to go into family medicine, and (3). reported that the faculty member they most wanted to be like was a family physician. In schools with decreases in family medicine graduates, there was a significant increase in the proportion of graduates intending a large city or suburban practice. Using binary logistic regression, the variables that remained significantly correlated with attending a school with increases or decreases in students selecting family medicine were the number of required clinical rotations in family medicine and primary care, the perception of the clinical competence of the family medicine faculty, and an intent to practice, or subsequently having a practice, in a rural area., Conclusions: Schools that want to increase their production of family physicians should consider admissions policies that select students inclined toward family medicine and rural practice, should adopt a curriculum that maximizes clinical training with family physicians and other primary care physicians, and should ensure that their family medicine faculty are perceived as competent role models.

Purpose: To evaluate the outcomes of combined internal medicine and pediatrics (IMP) residency programs using the published literature., Method: A literature search was conducted using Medline. Published articles were categorized as research or non-research (commentary, program requirements, program descriptions). Research articles were summarized and the results grouped under ten outcome variables., Results: Of the 32 articles located, 18 were research articles, of which only four had been published since 1993. All the research conducted was cross-sectional and most involved surveys of program directors (seven studies) or graduates (four studies). At the time the studies were conducted, 20-33% of IMP residents did not complete their combined training; attrition rates have not been documented recently. Approximately 80% of IMP graduates achieved certification in both specialties, one third subspecialized to some degree, and 80% provided care to both adults and children. One fourth of the graduates felt that more training was needed in ambulatory settings and less was needed in intensive care. Very few studies of the outcomes of IMP physicians were found., Conclusion: The outcomes of IMP residency programs are important for health workforce policy, and this study documents a need for more extensive research on the outcomes of training programs for primary care physicians.

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.

Background: Videotapes have been variably successful in teaching physical examination skills, interviewing strategies, and clinically relevant didactic material to medical students, residents, and physicians. The literature does not include evaluations of their success in introducing procedural techniques into clinical practice., Objectives: This study assessed whether the presentation of an instructional videotape influenced the adoption of a specific technique, assisting birth in the lateral position., Methods: Family practice residents, faculty, and physicians participated in educational presentations that reviewed how to assist childbirth in the lateral position. Three different formats were used for the presentations; an instructional videotape formed the core element of each presentation. Immediately following the presentations, and on one other occasion 4-6 months later, the participating physicians received questionnaires surveying their use of the lateral birth position., Results: Approximately 30% of the respondents who had not previously used the position used the lateral birth technique. Of the remaining respondents who had not used the technique, 64% considered using the technique with their laboring patients. Physicians who viewed the videotape in concert with other educational interventions were more likely to have adopted the new birth technique (P = .03)., Conclusions: An instructional videotape, as part of a structured, interactive presentation, can be used successfully to introduce a procedure into the clinical practices of family physicians.

This study was conducted to determine the frequency of behavioral risk factor screening and counseling by family medicine residents. Patients seen for well-care visits reported that residents screened most often for smoking and alcohol abuse. Residents inquired about stress, sedentary life-style, poor nutritional habits, and obesity less often. Few patients were counseled to reduce risks, even when unhealthy behaviors had been identified. Residents provided counseling most often for obesity, smoking, and stress; sedentary life-style, poor nutritional habits, and alcohol abuse rarely received intervention. Chart documentation of screening reported by patients was done a majority of the time only for smoking and alcohol abuse. Counseling was usually not documented. Residents screened most often for those risk factors (smoking and alcohol) they considered the most important causes of chronic disease. No relationship was found, however, between resident attitudes and likelihood of counseling. Residents agreed they needed more training to counsel patients on reducing behavioral risks.

Continuity of relationship between physician and patient is a fundamental aspect of the health care provided by family physicians. Measurement of continuity has proved difficult, however. Commonly applied measures, usual provider of care (UPC), continuity of care (COC), and the modified continuity index (MCI), either ignore key aspects of continuity or provide misleading results. Consequently, a new measure of continuity, the modified, modified continuity index (MMCI), with a possible range of 0 to 1, was developed to overcome these problems. It was applied to a residency model practice, in which mean MMCI was found to be 0.59 (range 0.3 to 1.0). Mean COC was .41 and a mean MCI was .44. Thus, unlike COC and MCI, MMCI suggests fairly good continuity of care in this practice while still implying possible improvement. The MMCI should be useful for enhancing training and practice of family medicine.

Previous research has identified five characteristics of medical schools that are related to the choice of family medicine as a specialty: (1) the amount of time devoted to required training in family medicine, (2) the timing of the required family medicine training, (3) the type of ownership of the school (public or private), (4) the geographic location of the school, and (5) the administrative structure of family medicine within the school. These five characteristics of U.S. medical schools during the mid-1980s, together with the school tuition levels, were examined with both univariate and multivariate analysis to observe their relationships to the percentage of U.S. medical graduates entering family medicine between July 1986 and December 1987. With univariate analysis, each characteristic was significantly related to the percentage of graduates entering family medicine. Using multivariate analysis, only the number of weeks required and the type of ownership of the school were significantly related to the percentage of graduates entering family medicine, with the higher percentages related to greater numbers of required weeks of family medicine training and to public ownership of the school.

A study was carried out to see if medical costs could be lowered by educating twenty six family practice residents and their patients. Four study conditions were were created: both resident and patient educated, resident only educated, patient only educated, and neither educated. Encounter data were collected before and after the resident education phase and a follow-up phone call was made to patients to obtain information on their current health. Cost measures included 1) physician's fee, 2) laboratory fees and 3) total ambulatory costs. Costs were lowered only in the both-educated group for laboratory costs. It was not sufficient to educate only residents, the group generally targeted for education about cost. This finding suggests that the most effective educational programs may involve patients as well as physicians.