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Background: The purpose of this study was to examine outpatient precepting for international medical graduates (IMGs) in family medicine residencies. The education of IMGs in residency programs has been a subject of concern. Multiple obstacles in acculturation may negatively influence IMGs' thoughts/feelings and subsequently affect their learning in teacher-learner interaction especially during a time-constrained environment like outpatient precepting. However, there is no research on IMGs' thoughts and feelings during outpatient precepting., Methods: We used qualitative research using multiple methods, primarily semi-structured individual interview during Interpersonal Process Recall (IPR). We purposefully sampled IMGs from three family medicine residency programs and videotaped their outpatient precepting. As a standard for comparison, we also videotaped US medical graduates (USMGs). We used multiple methods to explore their thoughts/feelings during precepting: brief interview, preceptor questionnaire, video review, and IPR debriefing of the precepting encounter. For analysis, we developed thematic codes from IPR transcripts and explored their consistency with data from the three other sources., Results: Seven themes emerged: cultural differences, language barriers, clinical performance, relationship, preceptor's teaching behaviors/attitudes, internalized process, and external factors. IMGs experienced various negative thoughts and feelings related to language barriers and cultural differences. These internalized processes adversely influenced their learning attitudes, precepting behaviors, and clinical performance., Conclusions: Precepting is more stressful for IMGs than for USMGs. IMGs need more specific orientation for outpatient precepting, and preceptors need further opportunity to reflect on their precepting skills for IMGs. Residency programs may do well to develop and test a curriculum and learning environment to meet IMGs' special needs.

Objective: To determine the acceptance and attitudes of family medicine physicians, clinical and nonclinical office staff, pharmacists, and patients during pharmacist integration into a medical home., Design: Qualitative study., Setting: Pittsburgh, PA, area from August 2009 to June 2010., Participants: Physicians, staff, pharmacists, and patients at four single-specialty family medicine office practices functioning as medical homes., Main Outcome Measures: Attitudes, acceptance, barriers, and problems identified by participants., Results: A total of 84 interviews were conducted: 21 interviews with family medicine physicians, 26 with patient care staff, 9 with nonclinical staff, 13 with patients, 6 with pharmacists, and 8 with office managers. Five main themes emerged from each group regarding the integration of a pharmacist, including positive overall feeling; clinical, educational, and time-saving benefits to the various groups; challenges understanding the role of the pharmacist; improved workflow and integration resulting from pharmacist flexibility and motivation; and suggestions to increase the pharmacists' time in each office. Pharmacists felt that they were accepted within 6 months of the integration process and that time management was a challenge., Conclusion: Participants felt that inclusion of a pharmacist into their practice improves the quality of patient care, provides a valuable resource for all providers and staff, and empowers patients. The initial concerns of the clinical and nonclinical staff disappeared within the first months of pharmacist integration. These results provide guidance to clinicians and insight into strategies for building a pharmacist-integrated medical home team.

Five years after retiring from family practice, I still miss my patients.

Purpose: To assess the efficacy of oral probiotics in adults with lactose intolerance through a systematic review of its effects on symptoms and breath hydrogen tests, and whether adding probiotics to nonfermented dairy products decreases lactose intolerance at that meal., Methods: We searched randomized controlled trials published between 1966 and December 2002. Databases in the search strategy included Medline and AMED. We reviewed references of clinical trials and contacted authors of major articles and manufacturers of probiotic commercial products. Quality assessment was based on the McMaster guides and was performed by 5 independent reviewers. Data extraction was performed by 2 reviewers., Results: A master list of 90 articles was compiled. Ten articles met inclusion and exclusion criteria and were consistent with our clinical question. Of the 9 studies that measured breath hydrogen, 3 were positive, 3 were negative, and 3 had both positive and negative results. Of the 7 studies that measured symptoms, 1 yielded positive results, 5 were negative, and 1 had both positive and negative outcomes., Conclusions: Probiotic supplementation in general did not alleviate the symptoms and signs of lactose intolerance in adults in this review. Some evidence suggests that specific strains, concentrations, and preparations are effective. Further clinical trials of specific strains and concentrations are necessary to delineate this potential therapeutic relationship.

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.

Background: Balint seminars are part of the education of family practice residents in an estimated 30% of programs. Balint leaders are family physicians, psychiatrists, psychologists, and social workers with apprenticeship-type training. Balint leaders or Balint groups have never been formally evaluated., Methods: We used multiple qualitative methods, including field observations, interviews, and focus groups. Field observations involved 12 Balint groups in 3 family practice residency programs. For comparison, we used videotaped seminars of 2 groups from the most recent Balint International meeting. In-person or telephone interviews were conducted with Balint leaders in a number of sites. We conducted focus groups with resident participants at each of the local sites., Results: Although differences were seen among groups influenced by the group leader and the makeup of the group, there were consistencies across all of the groups. Contrary to the usual description of Balint leadership, these residency groups functioned partially as support groups, attempted to relieve or dampen anxiety, had a hierarchical system with the leader as the teacher/controller, and served an educational and a developmental purpose., Conclusions: Balint leaders and their groups in the program studied did not function as traditionally described by Balint. Further observations of more groups are needed to determine if this variation is unique to the programs studied or is a manifestation of the transfer of the Balint method from experienced practitioners to physicians in training. This information will be of benefit to the development of appropriate training for future Balint leaders and for the credentialing process now being developed by the American Balint Society.

Background: The purpose of this study was to determine if therapeutic touch, an alternative medicine modality, is effective in the treatment of osteoarthritis of the knee., Methods: A single-blinded randomized control trial was conducted in a family practice center of a community hospital family practice residency program in Pennsylvania. The patients were between the ages of 40 and 80, had been given a diagnosis of osteoarthritis of at least one knee, had not had knee replacement, and had no other connective tissue disease. The patients were randomized to therapeutic touch, mock therapeutic touch, or standard care. The main outcome measures were pain and its impact, general well-being, and health status measured by standardized, validated instruments, as well as the qualitative measurement of a Depth interview., Results: Twenty-five patients completed the study. The treatment group had significantly decreased pain and improved function as compared with the placebo and control groups. The qualitative Depth interview confirmed this result., Conclusion: Despite the small numbers, significant differences were found in improvement in function and pain for patients receiving therapeutic touch. A larger study is needed to confirm these results. Alternative therapies can neither be accepted nor rejected without being subjected to the scientific method.

Background and Objectives: This descriptive study sought information on the types of clinical practice arrangements and the nature of clinical responsibilities of full-time physician faculty in family practice residency programs., Methods: A four-page, 37-item, self-administered questionnaire was sent to a 20% proportionate, systematic randomly sampled group of family practice faculty. Simple descriptive statistics were used for demographic and clinical practice data. Clinical practice characteristics were compared by the three most frequent clinical practice arrangements (private practice, on-site practice, and off-site practice) to determine differences., Results: The majority of respondents were white, board-certified males. Most faculty saw patients two (26.9%) or three (27.7%) half days per week and between 6-10 (47.5%) and 11-15 (41.1%) patients per session. The most frequent clinical practice arrangements were having faculty see patients in their own private practice (5.3%), as part of the faculty practice in the residency program's health center (72.9%), and as part of the faculty practice remote from the residency program's health center (11.7%). There were no differences among the three arrangements with respect to clinical sessions per week, taking call at night to back up the resident on call, seeing patients outside of regularly scheduled office hours, making house calls, following patients in the nursing home, or offering pregnancy care., Conclusions: Further research is needed to determine the advantages and disadvantages of different clinical practice arrangements for the clinical skills and role-modeling ability of family physician faculty.

Background: In a previous study we found immediate effectiveness of a nurse-initiated intervention on improving mammography recommendation rates in a family practice residency program. To determine the long-term effectiveness of this ongoing intervention, we performed a chart audit study on two different groups of charts 5 years after the institution of the intervention., Methods: Chart audits for mammogram recommendation and completion rates were conducted on an original cohort group of women aged 40 years and older (n = 91) and a new 5-year postintervention group of women aged 53 years and older (n = 189). Preintervention, postintervention, and 5-year postintervention rates were compared within the cohort group. Rates of the new 5-year postintervention group were compared with rates of women 50 years and older from the original preintervention group and postintervention group., Results: For the original cohort group the improvement in "mammograms done at least once in the past 3 years" was maintained 5 years later, and there was a statistically significant increased rate from the postintervention to 5 years later (73.9 percent versus 86.8 percent, P < 0.02) for "mammograms done or recommended at least once in the past 3 years." This improvement was also noted for the new 5-year postintervention group when their rates were compared with the preintervention and postintervention group rates. For "mammograms done at least once in the past 3 years," the rates were 34.2 percent, 45.5 percent, and 64 percent, respectively. For "mammograms done or recommended at least once in the past 3 years," the rates were 42.6 percent, 72.7 percent, and 90.0 percent, respectively. In a separate analysis, annual mammogram rates in the new 5-year postintervention group for the 3 years preceding this study were 44.8 percent (1990), 36.5 percent (1991), and 36.5 percent (1992). Eleven percent of women had a mammogram done in each of the 3 consecutive years., Conclusion: An ongoing nurse-initiated intervention is a feasible method of improving and maintaining mammogram recommendation and completion rates. Further studies of interventions to improve the rate at which eligible women get consecutive annual mammograms are needed.

Objective: To assess the long-term effect of an extensive rheumatology curriculum on graduates of family practice residencies., Design: Cohort analytic study using a mailed survey and a multiple-choice test based on clinical vignettes that were administered 3 to 7 years after graduation from residency training., Participants: Practicing family physicians who had graduated from a community hospital family practice residency with an extensive rheumatology curriculum (trained) were compared with graduates from a similar program without specific rheumatology training (untrained)., Main Outcome Measures: Total test scores, results of individual test questions, practice style, and attitudes toward rheumatology training and practice., Results: We received 39 (85%) responses from 46 potential respondents in the trained group and 25 (89%) responses from 28 potential respondents in the untrained group. Physicians in the two groups had similar backgrounds and practice styles. The trained physicians scored higher on the multiple-choice test (mean +/- SD, 25 +/- 5 vs 22 +/- 6; P < .03). The clinical significance of these differences is a matter of individual interpretation. One hundred percent of the trained physicians believed that the quality of their rheumatology training was good to excellent compared with 25% of the untrained physicians. Seventy-six percent of the untrained physicians wished that they knew more about rheumatology. No variables other than rheumatology training accounted for the differences between the two groups., Conclusions: The difference in rheumatology knowledge, evident during and soon after residency between trained and untrained physicians, persists for 3 to 7 years.

Background: Newsletters are marketed to physicians to provide a concise, accurate, and timely overview of the medical literature. The goal of these newsletters seems to be to present information that can be a suitable substitute for reading the original article. The purpose of this paper is to describe and evaluate newsletters pertinent to family physicians., Methods: Newsletters appropriate for family physicians were selected by collecting newsletter advertisements and by searching newsletter directories. A 3-month sample and pertinent data were collected from the publishers. Evaluation criteria included accuracy and completeness of the abstracts, scope of coverage of the medical literature, and relevance of article sources., Results: Eight newsletters were collected and evaluated. Accuracy was high for the evaluated abstracts. Abstract completeness averaged only 70 percent (range 55 percent to 92 percent). The type and source of abstracted articles varied widely among the newsletters., Conclusion: Newsletters available to family physicians vary widely; personal evaluation should supplement the results of the evaluation.

This study tested the feasibility of a low-technology office-based approach to weight reduction in obese hypertensive patients. Family practice residents were randomly assigned to either an experimental or a control group. Physicians in the experimental group were instructed in methods of weight reduction, which they then passed on to their patients. Patients of experimental physicians were seen monthly, their diets were discussed, and improvements were suggested. The control group patients received their usual care. After six months the experimental patients had lost significantly more weight than the controls and had significantly reduced the number of antihypertensive drugs while maintaining blood pressure control. After 12 months there was no significant difference between the two groups with respect to weight loss, blood pressure, or number of antihypertensive drugs. Experimental and control patients who lost weight had visited their physicians more frequently than those who did not and had reduced the number of antihypertensive medications they were taking. This educationally oriented intervention trial is an example of the type of research that is practical to perform in a family practice center and is applicable in family physicians' offices.

A new family practice residency curriculum in the format of the special requirements for residency training is proposed. This new curriculum consolidates the original principles of family practice with current developments in medical practice and changes in society. The emphasis is on increased flexibility, a competency-based curriculum, an extensive evaluation and audit system, curricular control by family practice faculty, increased ambulatory care training, a commitment to the biopsychosocial model and community-oriented primary care, and the reiteration of the basic core of medical knowledge and clinical skills.

We attempted to improve our compliance with recommendations for screening mammography, according to the American Cancer Society (ACS) guidelines, for eligible women patients seen by family practice residents by using a multipart intervention designed to eliminate identified barriers of knowledge and behavior on the part of the residents. Copies of the ACS cancer screening guidelines were posted in all examination and conference rooms and were provided to all residents. The intervention addressing the behavioral barriers had three components: (1) identification by the nursing staff of eligible women who were overdue for a mammogram as they presented for care, (2) completion of a checklist by residents indicating whether a mammogram was or was not recommended and why, and (3) a nurse-initiated backup reminder system for patients who escaped the primary checklist system. An audit of 200 preintervention and 270 postintervention charts showed statistically and clinically significant increases in mammograms recommended or done. Similar statistically significant increases were found in a cohort of 111 charts of patients in both the pre- and the postintervention audits. Results indicate that an intervention designed to eliminate identified resident-dependent barriers to compliance with screening mammography guidelines can be effective in increasing recommended mammography rates.

A predictive instrument (or index) previously reported to be of value in reducing unnecessary coronary care unit admissions was tested in a randomized study. Acceptability to the physician was then measured by monitoring utilization in a subsequent nonrandomized phase and by debriefing. The predictive instrument retained predictive accuracy in the new setting with good correlation between predicted and actual risk of acute cardiac ischemia (r = 0.925). False-positive diagnosis rate decreased from 71 percent to 0.0 percent (P = .0096) in a subgroup admitted to the intermediate care unit, consistent with previously reported usefulness in low-risk patients. Acceptability was poor, however, with utilization rate of only 2.8 percent of eligible patients. Debriefing revealed low perceived usefulness. This problem will need to be addressed if widespread utilization is to occur. The criteria of predictive accuracy, usefulness, and acceptability are suggested as a standard panel for testing new predictive instruments.

A multicenter, double-blind, randomized, placebo-controlled trial was conducted to determine whether the addition of penicillin was superior to patient education and anti-inflammatory drug therapy for relief of the acute discomforts of pharyngitis caused by group A beta-hemolytic streptococcus (GABHS). One hundred seventy-eight patients, aged 4 to 29 years, received appropriate symptomatic therapy, including specific doses of aspirin or acetaminophen, plus penicillin (91 patients) or placebo (87) for the initial 48 hours of illness. All had 24-hour office and 48-hour telephone reevaluations. In 123 patients (57 with clinically severe pharyngitis), throat cultures yielded GABHS. Penicillin provided a margin of 20% improvement over anti-inflammatory therapy for the complaint of sore throat only after 48 hours of treatment (for the 123 patients with GABHS, p = 0.01; for the 57 with both severe pharyngitis and GABHS, p = 0.05). No significant improvement was noted for fever, malaise, odynophagia, exudate, adenitis, or pharyngitis. The failure of penicillin to provide much additional benefit makes its routine early prescription specifically for symptomatic relief questionable.

Basic science education of physicians has been almost exclusively in the biological fields. Although in recent years many schools have added behavioral sciences to the preclinical curriculum, there has been no agreement as to content or method in this area. An understanding of human behavior is essential for all physicians and is the goal of the course described here. This course, entitled "Introduction to Patient Care," utilizes readings, group presentations, site visits, small-group seminars, and specifically stated educational objectives to present the following topics: health problems of the United States, physicians and other healers, humanistic values--the sick role, and the doctor-patient relationship. The small-group seminars, with behavioral science and clinical faculty, help to guide the student's learning experience toward a scientific analysis of the art of medicine.

Decisions regarding residency training require repeated reevaluation of organization and curriculum. Developing an autonomous inpatient teaching service may become necessary in many community hospitals because of a new competitive environment. To predict the impact of this possible change in one community program, we performed a retrospective analysis of 2,735 admissions to a community hospital during a one-year period. Residents' cases were compared with those of practicing family physicians and general internists. If family practice residents in this hospital were limited to an autonomous service, their overall experience and management of patients would be comparable to practicing primary care physicians in the same community hospital. However, volume would be inadequate and exposure to certain types of problems and situations would be limited. In multivariable analysis age, payment status, total consultation rate, many diagnostic categories, and some specific diagnoses separate residents from practicing physicians. As a particular example, internists have a concentration of geriatric patients and patients with cardiovascular disease. In order to utilize this experience, family practice residents in this hospital cannot rely solely on an autonomous teaching service.

Maintaining an adequate patient volume is a new concern for primary care physicians. Retaining active patients may be as important as recruiting new patients. A mail survey was conducted using a random sample of patients not returning for care over a three-year period in a primary care office. Over half of the inactive patients were transient, never having established themselves with the practice. One third of regular attending inactive patients had changed physicians, whereas the others had simply not returned for care. Patients who had changed physicians were more likely users of emergency rooms or drop-in clinics, had more negative feelings while in physicians' offices, were less satisfied with their own present physicians, and had less positive attitudes toward physicians in general. Inactive patients who had not changed physicians were as satisfied with their own physicians and with physicians in general as the active patient control subjects, even though they used services infrequently, usually for acute care. Investigating transient patients and those who are inactive but remain with a practice would positively affect patient volume and would likely benefit these patients as well. Primary care physicians should survey their own inactive files before embarking on other marketing techniques.