Rural training tracks in four family practice residencies.

The use of rural training tracks (RTTs) in family practice residencies is a new strategy (beginning in the late 1980s) to increase the number of residents selecting rural careers. The authors describe the four residencies (in Washington, Nebraska, New York, and Kentucky) that have established RTTs. The first residency year is completed in an urban tertiary care center, and the second and third years are completed in a distant rural community wherein the primary faculty are the members of a rural family practice group. Inpatient experience for the residents is provided by community hospitals that offer obstetrics, emergency room care, and first-line critical care. The residents' training is supplemented by specialty faculty practicing in the rural communities. The curricula are highly structured and are evaluated to ensure training experiences of high quality. The RTTs' financial support comes from state initiatives, hospital reimbursement, recruitment budgets, and outpatient care revenues. The authors conclude that the RTT concept has the potential to lessen the shortage of rural physicians.

Two decades of experience in the University of Washington Family Medicine Residency Network: practice differences between graduates in rural and urban locations.

This study describes how graduates of the University of Washington Family Medicine Residency Network who practice in rural locations differ from their urban counterparts in demographic characteristics, practice organization, practice content and scope of services, and satisfaction. Five hundred and three civilian medical graduates who completed their residencies between 1973 and 1990 responded to a 27-item questionnaire sent in 1992 (84% response rate). Graduates practicing outside the United States in a specialty other than family medicine or for fewer than 20 hours per week in direct patient care were excluded from the main study, leaving 116 rural and 278 urban graduates in the study. Thirty percent of graduates reported practicing in rural counties at the time of the survey. Rural graduates were more likely to be in private and solo practices than urban graduates. Rural graduates spent more time in patient care and on call, performed a broader range of procedures, and were more likely to practice obstetrics than urban graduates. Fewer graduates in rural practice were women. A greater proportion of rural graduates had been defendants in medical malpractice suits. The more independent and isolated private and solo practice settings of rural graduates require more practice management skills and support. Rural graduates' broader scope of practice requires training in a full range of procedures and inpatient care, as well as ambulatory care. Rural communities and hospitals also need to develop more flexible practice opportunities, including salaried and part-time positions, to facilitate recruitment and retention of physicians, especially women.

Rural and urban physicians: does the content of their Medicare practices differ?

Rural and urban areas have significant differences in the availability of medical technology, medical practice structures and patient populations. This study uses 1994 Medicare claims data to examine whether these differences are associated with variation in the content of practice between physicians practicing in rural and urban areas. This study compared the number of patients, outpatient visits, and inpatient visits per physician in the different specialties, diagnosis clusters, patient age and sex, and procedure frequency and type for board-certified rural and urban physicians in 12 ambulatory medical specialties. Overall, 14.4 percent of physicians in the 12 specialties practiced exclusively in rural Washington, with great variation by specialty. Rural physicians were older and less likely to be female than urban physicians. Rural physicians saw larger numbers of elderly patients and had higher volumes of outpatient visits than their urban counterparts. For all specialty groups except general surgeons and obstetrician-gynecologists, the diagnostic scope of practice was specialty-specific and similar for rural and urban physicians. Rural general surgeons had more visits for gastrointestinal disorders, while rural obstetrician-gynecologists had more visits out of their specialty domain (e.g., hypertension, diabetes) than their urban counterparts. The scope of procedures for rural and urban physicians in most specialties showed more similarities than differences. While the fund of knowledge and outpatient procedural training needed by most rural and urban practitioners to care for the elderly is similar, rural general surgeons and obstetrician-gynecologists need training outside their traditional specialty areas to optimally care for their patients.

The locum tenens experience: a comparison with a university faculty practice.

A locum tenens experience may be an effective mechanism by which the academic family physician can periodically enhance his or her clinical skills. This report compares the content of one of the author's locum tenens sessions to that of his university based practice. The locums resulted in an exposure to a concentrated, wide-spectrum practice highlighted by acute medical and surgical problems--in comparison with a more continuity-oriented university profile. Academic family physicians who realize high levels of nonclinical obligations may find the routine scheduling of a locum tenens rotation a valuable clinical adjunct.

A comparison of student clerkship experiences in community practices and residency-based clinics.

BACKGROUND: In our required family medicine clerkship, we used data from student logbook records of clinical experience to compare the learning experiences of students in community practices and residency-based clinics. METHODS: Sixty-eight University of Washington students collected data on patients seen during the final two weeks of their family medicine clerkships. We compared patient demographics, location of patient encounters, and clinical problems seen at nine residency and eight community locations in a four-state area. National Ambulatory Medical Care Survey data were used to compare student experiences to national practices. RESULTS: Log data documented that both community practices and residency sites met the course curriculum goals. Some variations occurred between the two types of clerkship sites, however. Students at community practices saw a higher mean number of patients and did more procedures than students at residency sites. Students at residencies were more likely to see patients for health maintenance and pregnancy care and less likely to see lacerations, sprains or strains, and some chronic diseases. CONCLUSION: Episodic log data were successfully used to monitor the objective educational strategies for residency- and community-based student clerkship sites. Although all students met clerkship objectives, there were significant differences in certain aspects of students' clinical experiences at the two types of clerkship sites.

An evaluation of computerized documentation of resident experiences in training.

This paper describes an evaluation of the University of Washington family practice project to document resident experiences in training. The production of aggregate reports using clustering techniques and peer group comparisons were well received by residents and faculty. A questionnaire survey and personal interview with a sample of faculty and residents analyzed attitudes toward the usefulness of such a documentation system as well as the actual uses of the reports produced. Documentation of inpatient and outpatient procedures was the most highly regarded application, but an overview of the scope and content of a resident ambulatory practice experience was also considered useful. Physician behavior was altered in subtle ways as a result of the feedback.

Clinical applications of computers in office practice.

The power to store and integrate vast amounts of information and to extract selected data rapidly makes the computer an obvious tool for physicians, particularly for family physicians, who attend to a large number of patients, deal with a great variety of problems, and provide comprehensive and long-term continuity of care. The ideal office computer system should be designed to permit each practice to select the business and clinical modules appropriate to that practice. The clinical modules would need to be sufficiently flexible to allow every physician to define the parameters he or she would wish to monitor for surveillance or health maintenance programs. There is an urgent need to arrive at some national consensus regarding the integration of clinical and business functions for office computers, particularly in family practice. Some pioneering physicians have shown the way. It now remains to translate the concepts into a generalizable system that would be suitable for a variety of settings.

Diagnosis clusters: a new approach for reporting the diagnostic content of family practice residents' ambulatory experiences.

Effective documentation and monitoring of the ambulatory care experiences of residents have been elusive goals of family practice educators. This article describes a method of aggregating the diagnostic (morbidity) data recorded by the residents using diagnosis clusters. Reports organized by diagnosis clusters are useful and easily interpreted. They facilitate the monitoring and documentation of the diagnostic profile and the recording habits of each resident.

Use of the international classification of health problems in primary care (ICHPPC-2) for reimbursement.

ICHPPC-2 is an international classification developed for use by primary care physicians. It is an official modification of ICD-9 and consists of only 362 diagnostic titles, which are directly comparable to arbitrarily selected ICD-9 rubrics. In the United States, third party reimbursement requires physicians to provide coded diagnostic information. These authors have arbitrarily assigned those code numbers from ICD-9-CM that are most likely representative of the type of health problems encountered by family physicians and therefore most appropriate for billing purposes where an ICD-9-CM code is required.

Physician knowledge and attitudes about health insurance after the introduction of capitated health care plans.

A two-part closed-end survey similar to a survey done in 1980 was given to 25 family physicians at an academic family medical center to assess physician knowledge about five insurance programs covering most of the patients seeking care in the center, and to assess physician attitudes about the capitated insurance plan with which the clinic was affiliated. Results did not differ significantly from those obtained in a similar survey four years earlier at the same center. Physicians correctly identified benefits offered by insurance programs only about one half of the time and many did not ascertain patient insurance coverage at all. Physicians considered the most important advantages of capitated health care to be the patient protection from fees for services obtained, the coverage for health care maintenance, and the potential for controlling health care costs. Physician-perceived disadvantages included difficulties controlling costs generated by other specialists, dealing with after-the-fact authorization requests, controlling access to services, and obtaining information about costs within the capitated system.

Growth and maturation of a model family practice: a five-year prospective study.

New medical practices go through a process of growth and maturation. In this study, a newly established model family practice was examined prospectively in order to describe the changes in the patient population and utilization patterns as the practice developed. Cross sections of the registered patient population were sampled randomly after the first and the sixth year of practice operation, and the results were analyzed. As part of the analysis, the population using the practice was examined from three points of view: those who were registered with the practice, those actually using the practice during the sample periods, and those using the practice "out-of-hours." During the five-year study period, practice volume tripled and the operation began to approach financial self-sufficiency. The characteristics of the patient population using the clinic changed markedly. The mean patient age increased, the number of welfare patients decreased, and the clinic population grew to resemble more closely the demographic profile of the surrounding area. The study proved to be very useful as a tool for examining the structure of this model family practice and evaluating the educational relevance of the patient population to the needs of the residents.

Characteristics of the residency interview process preferred by medical student applicants.

This study elucidates the characteristics of the interview day preferred by medical students applying to family practice residencies. Interviews and informal meetings with residents were regarded as being the most helpful, followed by interviews with the director or faculty. Perceptions of other components of the interview day are also described. October was the month most students preferred, and two interviews each lasting 20 to 30 minutes were considered ideal. Group interviews were regarded negatively. The results of this survey are generalizable to other residency programs and could be helpful in planning the interview day.

A system for drug utilization review in ambulatory care.

BACKGROUND: It is more difficult to conduct drug utilization reviews in ambulatory care settings than in inpatient care settings. This is true for several reasons: it is harder to identify outpatients who are receiving specific medications; often there is less evidence on which to base clinical standards for drug use; and it is more difficult to ensure patient compliance with drug therapy. METHODS: This article describes a drug utilization review system designed to operate in ambulatory care clinics. The system consists of (1) a computerized database for efficient identification of patients who receive prescriptions for a specific medication, (2) clinic-wide consensus guidelines, (3) reminders in the medical record, (4) regular chart audits, and (5) feedback to physicians. RESULTS: Experience in monitoring the use of serum theophylline assays illustrates how this system can be used in an ambulatory care clinic. According to guidelines adopted in our clinic, overuse of assays is not a problem. The system of physician reminders and chart audits can help prevent underuse. CONCLUSIONS: Despite the difficulties in conducting drug utilization reviews in the ambulatory setting, a system based on clinic-wide guidelines is feasible and should be an integral part of quality assurance programs.

An updated protocol for pediatric health screening.

Pediatric health screening comprises a significant component of a family physician's practice. A variety of protocols exist for pediatric screening yet many of the diseases included in such screening have marginal supportive evidence in the literature. This article examines 14 areas commonly included in pediatric health screening. Each is evaluated based on a thorough literature review, according to basic criteria necessary to justify periodic screening. Specific recommendations are made which are considered to be practical and appropriate in practice. These have been incorporated into the protocols currently used at the University of Washington Family Medical Center.

Hospital privileges for family physicians: documentation of family practice residents' experiences in training.

This report describes a study of the content and uses of the University of Washington Affiliated Residency Network documentation system for future hospital privileges. The selected procedures and problems considered important to document for future hospital privileges were validated by means of a graduate survey conducted in 1985. Fifty percent of the 43 graduates responding used their personal documentation when applying for hospital privileges. Intermediate-sized hospitals of 50 to 199 beds were significantly more likely to require documentation than either small (fewer than 50 beds) or large (more than 200 beds) hospitals. However, 84 percent of the hospitals where graduates are located either require documentation or would find it helpful for privilege application. The three-year cumulative experiences of the 1986 cohort of graduating residents are also presented. Thirty-six of the residents (71 percent) participated actively in the voluntary network documentation system. None of the items selected as important to document for future hospital privileges were recorded by 100 percent of the residents. Obstetric procedures and problems were the items most commonly documented.

Clinical comparison of microscopic and culture techniques in the diagnosis of Candida vaginitis.

This study compares potassium hydroxide (KOH), Microstix-Candida, and Nickerson's medium with Sabouraud agar in the isolation of Candida. Of 204 symptomatic and asymptomatic women, 36 had Sabouraud cultures positive for Candida. The KOH preparation demonstrated both poor sensitivity and poor predictive value in the isolation of Candida, while Microstix-Candida and Nickerson's medium were statistically indistinguishable from Sabouraud agar. The use of either Microstix-Candida or Nickerson's medium is recommended in the evaluation of Candida vaginitis when the KOH preparation is negative.

Inpatient diagnosis clusters: analyzing hospital care in family practice.

Hospital care is an important component of family practice in the United States, but the study of this area has been impeded by the lack of a simple and clinically meaningful method of categorizing the diagnostic problems that make up the inpatient workload. This paper extends the method of diagnosis clusters--first used in the analysis of ambulatory care--to the hospital setting. Using the University of Southern California Medical Activities and Manpower Study of office-based general and family physicians, 52 clinically discrete diagnosis clusters were developed that include 78 percent of all principal diagnoses recorded in the hospital during the study interval. Fifty percent of all hospital encounters can be incorporated in only 15 clusters. Data clustered using this technique demonstrate that clinical problems such as ischemic heart disease and malignant neoplasms represent a major part of the family physician's hospital workload, a fact that has important implications for training and practice. Diagnosis clustering should facilitate further study of the hospital activities of primary care physicians.

A conversion code from ICHPPC-1 to ICHPPC-2.

Faculty members from four departments of family medicine participated in the production of a definitive conversion from the first to the second versions of the International Classification of Health Problems in Primary Care (ICHPPC). A detailed conversion code with the appropriate ICHPPC-2 equivalent for each ICHPPC-1 diagnostic title is provided. Differences between the two classifications are discussed and suggestions are made for the use of the conversion code.

A conversion code from the RCGP to the ICHPPC classification system.

Faculty members from four family medicine training programs participated in the production of a definitive conversion of the Royal College of General Practitioners Classification of Diseases as modified for use with problem-oriented medical records (RCGP) to the International Classification of Health Problems for Primary Care (ICHPPC). The method used to produce the conversion and the several problems encountered are described. A detailed translation with the appropriate ICHPPC equivalent for each RCGP diagnostic title and code number is provided.

A computer-administered interview on life events: improving patient-doctor communication.

A computer-administered interview on life events (CAI-LEV) was developed for use by patients in the waiting room of the model family practice unit at the Medical University of South Carolina, Charleston, South Carolina. Computer printouts of CAI-LEV are immediately available for doctor/patient communication, so that CAI-LEV fits into ongoing patient flow and care. Throughout a three-month study, confidentiality of information was protected by the use of numbers for patient responses to questions in 16 areas covering a wide range of possible life events. The adept physician can utilize the printout to assess stress in the patient's current situation, to focus quickly on any particular area of concern, or to initiate a counseling session. Of some 250 completed interview, 93 have been reviewed by residents and faculty after in-depth utilization during patient care. Of these 93 physician-evaluated interviews, 40 percent yielded important new information, while in 22 percent of the cases, doctor/patient communication was improved.