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Background: Coronavirus disease 2019 (COVID-19) infection is associated with proinflammatory states and adverse health outcomes such as ST-segment elevation myocardial infarction (STEMI) and cerebrovascular accidents (CVA). Limited evidence suggests that COVID-19 vaccination may decrease the adverse impact of COVID-19 infections. This study was designed to determine if patients who received COVID-19 vaccination had lower mortality from STEMI and CVA., Methods: This is a retrospective comparative analysis of 3,050 patients, who were admitted to the hospital and diagnosed with STEMI or CVA between April 1, 2019, and April 1, 2022. Patients were divided into three different timeframes: pre-COVID (April 1, 2019, to March 31, 2020), COVID (April 1, 2020 to March 31, 2021), and post-COVID (April 1, 2021 to March 31, 2022). Chi-square analysis was completed to analyze associations between STEMI, CVA, and vaccination status. A multinominal logistic regression was used to determine significant predictors for in-hospital mortality., Results: A total of 3,050 patients were admitted (1,873 STEMI and 1,177 CVA). STEMI accounted for about 60% of cases in each of the three time periods. There was no statistical difference in STEMI or CVA percentages in the three time periods. There was increased mortality in STEMI and CVA patients (odds ratio (OR) = 11.4; P < 0.001), but patients who received the COVID-19 vaccine were less likely to die (OR = 0.51, 95% confidence interval (CI): 0.28 - 0.93; P < 0.027) when compared to those who were unvaccinated. There was increased risk of death in patients with atrial fibrillation (AFIB) (OR = 2.43; P < 0.001) and chronic heart failure (CHF) (OR = 1.76; P = 0.004). There was increased mortality risk associated with age (OR =1.03; P = 0.001). Patients with coronary artery disease (CAD) (OR = 0.45; P = 0.014) and hyperlipidemia (OR = 0.29; P < 0.001) were less likely to die., Conclusions: Vaccination against COVID-19 was associated with reduced mortality rates in patients hospitalized with STEMI and CVA. Patients with pre-existing cardiovascular comorbidities such as CAD and hyperlipidemia also had lower mortality., Competing Interests: The authors declare there is no conflict of interest., (Copyright 2024, Patel et al.)

Background and Objectives: In 1999 the University of Kansas School of Medicine established a rural option for the required family medicine clerkship to increase student exposure to rural locations. The emphasis at these sites was in experiential learning, and students did not attend lectures. To assure that students who chose the rural option were receiving an equivalent educational experience, we compared the performance of rural students to their peers that received the standard clerkship experience., Methods: We used data from family medicine clerkship students during 1999--2011 to compare rural students with those that remained on the main campus. Comparison of the groups was made with regard to previous academic performance and demographic data to assess for initial differences. While the rural students were more likely to be Caucasian, there was otherwise no statistical significance between the groups. We then compared their National Board of Medical Examiners (NBME) exam performance and their overall grade., Results: Students who chose a rural location had a significantly higher clerkship grade. This was due to higher clinical evaluations., Conclusions: Students who completed a rural family medicine clerkship are not at an academic disadvantage. There are many possible explanations for better clinical evaluations, and a comparison of performance on the clinical skills assessment would be useful to determine whether the increased clinical experience during the rural option created a difference in clinical skills.

The etiology of chronic obstructive pulmonary disease (COPD) is chronic lung inflammation. In the United States, this inflammation most commonly is caused by smoking. COPD is diagnosed when an at-risk patient presents with respiratory symptoms and has irreversible airway obstruction indicated by a forced expiratory volume in 1 second/forced vital capacity ratio of less than 0.7. Management goals for COPD include smoking cessation, symptom reduction, exacerbation reduction, hospitalization avoidance, and improvement of quality of life. Stable patients with COPD who remain symptomatic despite using short-acting bronchodilators should start inhaled maintenance drugs to reduce symptoms and exacerbations, avoid hospitalizations, and improve quality of life. A long-acting anticholinergic or a long-acting beta2-agonist (LABA) can be used for initial therapy; these drugs have fewer adverse effects than inhaled corticosteroids (ICS). If patients remain symptomatic despite monotherapy, dual therapy with a long-acting anticholinergic and a LABA, or a LABA and an ICS, may be beneficial. Triple therapy (ie, a long-acting anticholinergic, a LABA, and an ICS) also is used, but it is unclear if triple therapy is superior to dual therapy. Roflumilast, an oral selective inhibitor of phosphodiesterase 4, is used to manage moderate to severe COPD. Continuous oxygen therapy is indicated for patients with COPD who have severe hypoxemia (ie, PaO2 less than 55 mm Hg or an oxygen saturation less than 88% on room air). Nonpharmacologic strategies also are useful to improve patient outcomes. Pulmonary rehabilitation improves dyspnea and quality of life. Pulmonary rehabilitation after an acute exacerbation reduces hospitalizations and mortality, and improves quality of life and exercise capacity. Smoking cessation is the most effective management strategy for reducing morbidity and mortality in patients with COPD. Lung volume reduction surgery, bullectomy, and lung transplantation are surgical interventions that are appropriate for some patients with COPD., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Exposure to environmental pollutants can have short- and long-term effects on lung health. Sources of air pollution include gases (eg, carbon monoxide, ozone) and particulate matter (eg, soot, dust). In the United States, the Environmental Protection Agency regulates air pollution. Elevated ozone concentrations are associated with increases in lung-related hospitalizations and mortality. Elevated particulate matter pollution increases the risk of cardiopulmonary and lung cancer mortality. Occupations with high exposures to pollutants (eg, heavy construction work, truck driving, auto mechanics) pose higher risk of chronic obstructive lung disease. Some industrial settings (eg, agriculture, sawmills, meat packing plants) also are associated with higher risks from pollutants. The Environmental Protection Agency issues an air quality index for cities and regions in the United States. The upper levels on the index are associated with increases in asthma-related emergency department visits and hospitalizations. Damp and moldy housing might make asthma symptoms worse; individuals from lower socioeconomic groups who live in lower quality housing are particularly at risk. Other household exposures that can have negative effects on lung health include radon, nanoparticles, and biomass fuels., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Asthma is a common respiratory disease that leads to school and work absenteeism, office and emergency department visits, hospitalization, and mortality. Dyspnea and wheezing are caused by airway inflammation. Asthma severity scores are used to predict the risk of exacerbations. Severity assessment instruments include questions about daytime and nighttime symptoms, use of short-acting beta2-agonists, and the effect of symptoms on daily activities. The 4 components of effective asthma management are monitoring, education, control of environmental factors, and pharmacotherapy. Several national quality measures are used to measure asthma care. The National Healthcare Quality & Disparities reports measure use of drugs, routine examinations, smoking cessation, influenza vaccination, emergency department visits, and urgent ambulatory visits. Electronic health records can be used to create asthma registries to identify patients who are at higher risk of exacerbations. Interventions that have been shown to improve asthma outcomes include asthma self-management and education, risk stratification of asthma patients, and improvement of drug adherence. Providing asthma education for patients and family members has been shown to decrease hospitalizations and emergency department visits., (Written permission from the American Academy of Family Physicians is required for reproduction of this material in whole or in part in any form or medium.)

Background and Objectives: Family medicine clerkship directors review students' patient encounter logs. Encounter data can be used to alter students' learning experiences. Our purpose was to determine if students record different types of patient encounters before and after reviewing log data with clerkship directors., Methods: Clerkship directors met with each student at clerkship midpoint, reviewed encounter data, and encouraged the student to seek out less frequently seen diseases., Results: A total of 56/105 students (53%) saw different types of patients after the review., Conclusions: More than half of the students recorded different types of patient encounters after an intervention encouraging them to do so.

Diagnostic errors are an important source of medical errors. Problematic information-gathering is a common cause of diagnostic errors among physicians and medical students. The objectives of this study were to (1) determine if medical students' information-gathering patterns formed clusters of similar strategies, and if so (2) to calculate the percentage of incorrect diagnoses in each cluster. A total of 141 2nd year medical students completed a computer case simulation. Each student's information-gathering pattern included the sequence of history, physical examination, and ancillary testing items chosen from a predefined list. We analyzed the patterns using an artificial neural network and compared percentages of incorrect diagnoses among clusters of information-gathering patterns. We input patterns into a 35 x 35 self organizing map. The network trained for 10,000 epochs. The number of students at each neuron formed a surface that was statistically smoothed into clusters. Each student was assigned to one cluster, the cluster that contributed the largest value to the smoothed function at the student's location in the grid. Seven clusters were identified. Percentage of incorrect diagnoses differed significantly among clusters (Range 0-42%, Chi (2) = 13.62, P = .034). Distance of each cluster from the worst performing cluster was used to rank clusters. This rank was compared to rank determined by percentage incorrect. We found a high positive correlation (Spearman Correlation = .893, P = .007). Clusters closest to the worst performing cluster had the highest percentages of incorrect diagnoses. Patterns of information-gathering were distinct and had different rates of diagnostic error.

Background: Clinicians cannot provide all recommended preventive services in a single office visit and must learn to prioritize. This skill is not overtly addressed in medical school., Methods: We designed a workshop to teach third-year medical students to prioritize preventive services during an office visit. In a prospective controlled trial, we compared performance on a standardized patient case., Results: Students performed well, but there was no significant difference between intervention and control groups' mean scores on the standardized patient encounter., Conclusions: Our brief intervention failed to increase students' scores on a standardized patient case requiring preventive services prioritization.

Background and Objective: The University of Missouri family medicine residency has 297 family physician graduates. We suspected that the practice patterns of graduates were changing., Methods: All graduates of the residency were surveyed in 1998, 2001, and 2004, asking about practice patterns. To characterize current practice characteristics and scope, we used the latest survey returned by each respondent. We analyzed data for persons who returned all 3 surveys to examine trends across surveys., Results: Annual response rates ranged from 58% to 78%. Of graduates who responded to all 3 surveys, fewer graduates care for patients in the hospital (71.3%, 1998; 56.5%, 2004), practice obstetrics (40.7%, 1998; 23.2%, 2004), or provide primary care for their patients in the emergency department (25.9%, 1998; 13.0%, 2004). Fewer recent graduates perform flexible sigmoidoscopy or exercise electrocardiograms. Graduates who are practicing obstetrics are more likely to be rural or to have graduated since 1994. Those performing flexible sigmoidoscopy are more likely to be male or to have graduated before 1994. The perceived need for more training in practice management is higher for more recent graduates (14.9% for 1975 to 1983 graduates; 31.9% for 1994 to 2003 graduates)., Conclusions: Across the 3 surveys, there was a decline in the proportion of graduates of this family medicine residency program performing procedures, obstetrics, intensive care unit care, or hospital medicine. This study highlights how the practices of family medicine residency graduates may change over time. Data regarding residency graduate practice profiles may help predict the knowledge and skills residency graduates will need in their future practices and evaluate the impact of the Future of Family Medicine recommendations.

Background: Tomorrow's physicians must learn to access, retrieve, integrate and apply current information into ambulatory patient encounters, yet few medical schools teach 'real time' information management., Methods: We compared two groups of clerkship students' information management skills using a standardized patient case. The intervention group participated in case-based discussions including exercises that required them to manage new information. The control group completed the same case discussions without information management exercises., Results: After five weeks, there was no significant difference between the control and intervention groups' scores on the standardized patient case. However, third rotation students significantly outperformed first rotation students., Conclusion: Case-based exercises to teach information management failed to improve students' performance on a standardized patient case. Increased number of clinical rotations was associated with improved performance.

Background and Objectives: Beginning in July 2002, all residencies were required to show that their residents were obtaining competency in six core areas defined by the Accreditation Council for Graduate Medical Education (ACGME)., Methods: In 2003, we surveyed all 444 family medicine program directors regarding the ACGME Core Competencies and how programs evaluated them., Results: A total of 287/444 (64.6%) responded. Almost all (279/287) had heard of the ACGME Core Competencies, and most (257/287) had begun to implement evaluation programs. Of program directors responding, 67.6% identified patient care as the most important competency. Evaluation methods most frequently used were active precepting (76.0%), record review (72.8%), and procedure logs (63.8%). The least commonly used tools were OSCE (9.1%), audit of computer utilization and knowledge (10.5%), and simulations (11.1%). Respondents identified time (74.3 %) and faculty development (13.0%) as primary implementation barriers., Conclusions: Program directors believe that patient care is the most important competency. Some programs are not yet attempting to address the competencies, and some were unaware of the accreditation implications of noncompliance with the Outcome Project. Time was identified as the major barrier to implementing core competency evaluation methods.

Background and Objectives: In 1992, with the approval of the American Board of Family Medicine (ABFM) (formerly known as the American Board of Family Practice), we established an accelerated residency program (ARP) involving five residency programs at the University of Tennessee (UT). An accredited resident can complete medical school and residency in a combined total of 6 years. This paper is a report of our experience with the ARP. Our objective was to determine if accelerated residents performed as well as or better than non-accelerated residents., Methods: Students are selected for the ARP on the basis of academic achievement, life experience, interviews, and commitment to family medicine. For the accelerated residents, we tracked outcomes measures, including medical school grade point average (GPA), US Medical Licensing Examination (USMLE) scores, ABFM In-training Examination scores, and board certification status., Results: From 1992 to 2002, 47 students entered the ARP at five UT residency programs. Five students did not complete the program. The average entering GPA was 3.17, and the average USMLE Step I score was 207. The accelerated residents, on average, performed better on ABFM In-training Examinations in the first and third years of residency than the non-accelerated residents did. Accelerated residents have a 100% ABFM certification rate. A total of 76% practice in Tennessee, and 65% began practice in a rural county., Conclusions: The UT ARP has been an effective means for allowing medical students to complete their family medicine training in 6 years. Accelerated residents have performed as well as or better than non-accelerated residents on standardized testing.

Purpose: Little information exists on how patients in medical practice use food package nutrition labels. We theorized that patients in a general medical practice might not make the distinction between serving size and total package nutrition information, and this might lead to obesity., Methods: Ninety patients between ages of 18 and 65 attending the St. Francis/University of Tennessee Family Practice Center were interviewed to determine whether they could calculate the total calories in sample snack food packages that contained more than one serving., Results: Ninety percent of our patient sample correctly identified the number of calories per individual serving, but only 37% were able to recognize that the sample packages contained multiple servings. Confusion between calories per serving size and total calories per package was correlated with lower educational levels (P =.011) and with the presence of cardiovascular heart disease in our patient sample., Conclusions: Our patients tended to think of a multiple serving package as one serving. They underestimated and under-reported caloric intake from snack food sources. We conclude that snack food labels as actually used by patients do not lead to informed dietary choices. These findings could impact our understanding and management of the obesity epidemic in the United States.

Ten percent to 40% of adults have intermittent insomnia, and 15% have long-term sleep difficulties. This article provides a review of the classification, differential diagnosis, and treatment options available for insomnia. We performed a MEDLINE search using OVID and the key words "insomnia," "sleeplessness," "behavior modification," "herbs," "medicinal," and "pharmacologic therapy." Articles were selected based on their relevance to the topic. Evaluation of insomnia includes a careful sleep history, review of medical history, review of medication use (including over-the-counter and herbal medications), family history, and screening for depression, anxiety, and substance abuse. Treatment should be individualized based on the nature and severity of symptoms. Nonpharmacologic treatments are effective and have minimal side effects compared with drug therapies. Medications such as diphenhydramine, doxylamine, and trazodone can be used initially, but patients may not tolerate their side effects. Newer medications such as zolpidem and zaleplon have short half-lives and minimal side effects. Both are approved for short-term use in the insomniac.

This paper describes a rural obstetric experience that was developed for a university-based family practice residency program and designed to increase the number of deliveries per resident, the number of graduates practicing in rural areas, and the number of graduates doing obstetrics. Rural hospitals can be a source of deliveries for residency training programs. This rural obstetric experience also offers more training months in a rural setting and more months training with family physicians.

Unlabelled: New electronic sources of information are available for medical students in their search for residency training programs., Methods: Senior students at the University of Missouri were surveyed regarding types and methods of information sought, and residency choice., Results: Response rate was 96 percent. Ninety-one point five percent used the Internet to access information. Eighty-six percent used a computer at medical school; seventy-eight percent used one at home. Sixty-five point one percent used the university's web site for information., Conclusion: Students use the world wide web and the Internet for accessing residency programs information.