Patient-Reported Prevalence, Characteristics, and Impact of Leg Cramps in an Urban Primary Care Clinic.

This study addresses the prevalence and characteristics of leg cramps in 294 primary care patients (mean age = 46.5 years), with 51.7% reporting leg cramps. Patients who experience resting or exercise-induced leg cramps were more likely to be older and female. Cramp severity averaged 5.6 on a scale of 1-10 and disturbed sleep "sometimes" or "often" in 55% of patients. Most patients did not discuss cramps with their clinician. Our study reveals a possible shift in patients who experience leg cramps to younger age and chronicity. Resting leg cramps should be reviewed by clinicians as a symptom of declining health and advancing aging.

BMI and Waist Circumference in Patients with Multiple Myeloma.

Context: Cancer is associated with many risk factors, including obesity. Specifically, abdominal obesity is linked to metabolic syndrome and is quantified by waist circumference (WC). Compared to WC, body mass index (BMI) is more accessible in the office to assess a patient's overall body fat composition. With preexisting computed tomography (CT) scans in multiple myeloma (MM) patients, WC can be obtained quickly and accurately as a potential prognostic biomarker. Objective: To determine if there is a correlation between BMI and WC in MM patients. Study Design and Analysis: This is a retrospective cohort study using preexisting CT scans of MM patients. Demographic information including age, sex, race, and BMI was gathered. The WC was obtained using Aquarius iNtuition software version 4.4.12. To standardize the CT scan measurements, slices were taken at the L3 vertebra with both transverse processes visible. Setting/Dataset: An academic midwestern healthcare system. Population Studied: A cohort of MM patients with CT scans. Intervention/Instrument: The scans were analyzed with Aquarius iNtuition. Outcome Measures: Average BMI and WC, as well as the correlation between BMI and WC. Results: This study includes 71 MM patients (37 women and 34 men) who had a whole-body low-dose CT scan. The average BMI was in the overweight range for both women and men at 28.7 and 28.8, respectively. Notably, the average WC was 39.4 inches for women and 41.9 inches in men, meeting one of the criteria for metabolic syndrome (>35 inches in women and >40 inches in men). BMI and WC were significantly correlated in both men and women (p <0.001). Conclusions: This is a retrospective analysis of BMI and WC in a cohort of MM patients. Traditionally, BMI has been used to quickly assess the body fat composition of patients. However, WC is a more accurate and readily accessible tool in patients with a CT scan. This measurement is strongly tied to metabolic syndrome and is part of the diagnostic criteria. We found that BMI and WC were significantly correlated in this cohort. Further follow-up is needed with a larger sample size and over a longer period. As body composition in this cohort has not been previously studied, further analyses may provide more biomarkers to aid in disease management.

Teaching module for obesity bias education: incorporating comprehensive competencies and innovative techniques.

BACKGROUND: The majority of the United States population is overweight or obese, and obesity bias is frequently reported by patients. Obesity bias is associated with adverse health outcomes, even independent of body weight. Primary care residents are often sources of obesity bias towards patients with weight, yet education regarding obesity bias is significantly lacking in most family medicine residency teaching curricula. The aim of this study is to describe an innovative web-based module on obesity bias and discuss its impact in family medicine residents. METHODS: The e-module was developed by an interprofessional team of health care students and faculty. It consisted of a 15-minute video containing five clinical vignettes that depicted instances of explicit and implicit obesity bias in a patient-centered medical home (PCMH) model. Family medicine residents viewed the e-module as part of a dedicated one-hour didactic on obesity bias. Surveys were administered prior to and following the viewing of the e-module. They assessed previous education on obesity care, comfort in working with patients with obesity, residents' understanding of their own biases in working with this population, and the anticipated impact of the module on future patient care. RESULTS: A total of 83 residents from three family medicine residency programs viewed the e-module and 56 completed both the pre and post survey. There was a significant improvement in residents' comfort in working with patients with obesity as well as their understanding of their own biases. CONCLUSION: This teaching e-module is a short, interactive, web-based educational intervention that is free and open-sourced. The first-person patient perspective allows learners to better understand the patient's point of view and its PCMH setting illustrates interactions with a variety of healthcare professionals. It was engaging and well received by family medicine residents. This module can begin the conversation around obesity bias, leading to improved patient care.

A clinical bulbar assessment scale (CBAS) for amyotrophic lateral sclerosis.

INTRODUCTION/AIMS: Comprehensive and valid bulbar assessment scales for use within amyotrophic lateral sclerosis (ALS) clinics are critically needed. The aims of this study are to develop the Clinical Bulbar Assessment Scale (CBAS) and complete preliminary validation. METHODS: The authors selected CBAS items from among the literature and expert opinion, and content validity ratio (CVR) was calculated. Following consent, the CBAS was administered to a pilot sample of English-speaking adults with El Escorial defined ALS (N = 54) from a multidisciplinary clinic, characterizing speech, swallowing, and extrabulbar features. Criterion validity was assessed by correlating CBAS scores with commonly used ALS scales, and internal consistency reliability was obtained. RESULTS: Expert raters reported strong agreement for the CBAS items (CVR = 1.00; 100% agreement). CBAS scores yielded a moderate, significant, negative correlation with ALS Functional Rating Scale-Revised (ALSFRS-R) total scores (r = -0.652, p < .001), and a strong, significant, negative correlation with ALSFRS-R bulbar subscale scores (r = -0.795, p < .001). There was a strong, significant, positive correlation with Center for Neurologic Studies Bulbar Function Scale (CNS-BFS) scores (r = 0.819, p < .001). CBAS scores were significantly higher for bulbar onset (mean = 38.9% of total possible points, SD = 22.6) than spinal onset (mean = 18.7%, SD = 15.8; p = .004). Internal consistency reliability (Cronbach's alpha) values were: (a) total CBAS, α = 0.889; (b) Speech subscale, α = 0.903; and (c) Swallowing subscale, α = 0.801. DISCUSSION: The CBAS represents a novel means of standardized bulbar data collection using measures of speech, swallowing, respiratory, and cognitive-linguistic skills. Preliminary evidence suggests the CBAS is a valid, reliable scale for clinical assessment of bulbar dysfunction.

Outcomes of a US-Sino family medicine leadership program.

BACKGROUND AND OBJECTIVES: The purpose of this study was to determine the outcomes of a two- week US-Sino Family Medicine Leadership Symposium for medical educators from China and how participants have integrated their learning into their teaching and practice of medicine. METHODS: Teaching topics emphasized principles of family medicine, teaching methods, assessment, and curriculum development. Each cohort received a wide range of practical, didactic and hands-on learning experiences. Online surveys were distributed anonymously to participants from the 2013-2019 cohorts to assess learner opinion and learner behavior change as a result of the leadership symposium. Quantitative measures assessed their level of integration of the topics into teaching and clinical practice and their satisfaction in the areas of teaching and leadership. They were also asked to provide qualitative feedback regarding incorporation of the content into their work. RESULTS: The survey response rate was 47.6% (39/82). Respondents stated that they incorporated topics such as basic interviewing skills and information on the patient-centered medical home into their teaching in China. The most applied clinical skills they were able to incorporate into their clinical environment in China included: Breaking Bad News, Simulations Sessions with practice, One-Minute Preceptor, and Interprofessional Education. CONCLUSIONS: Results indicate that participants have demonstrated behavior changes that have led to the incorporation of the content into teaching and clinical practice. We demonstrated effectiveness of the curriculum in cultivating the teaching and practice of family medicine. The program appears to be a positive experience that has led to embracement of the roles as trainer and leader. 100% of the participants who completed the survey felt that the program improved patient confidence in their ability as a family doctor. Future assessment on barriers to their progress as teachers and leaders in family medicine would be helpful to explore.

Utilization of Health Care Resources by the Amish of a Rural County in Nebraska.

The medical needs of the New Order Amish (NOA) remain poorly understood. The NOA community in Pawnee County, Nebraska was founded in 2011 by members from across the Midwest. Understanding what this community wants from their medical providers informs how rural hospitals may best serve the needs of growing NOA populations. To address this, the current utilization of the closest healthcare resource to community were assessed. Medical records data for Amish patients were obtained at Pawnee County Memorial Hospital and Rural Health Clinic from 2011 to 2016. Subjective data were obtained by surveys and interviews administered to Amish in Pawnee County. The 422 complete interactions in the medical record covered most primary care complaints. The fifteen survey respondents valued direct interaction with providers and expressed concerns about cost, emergencies, and access to obstetric practice. Surprisingly, though surveys indicated minimal use of health establishments for many common health complaints, medical records indicated frequent doctor visits for myriad reasons. Naturalistic books were the most utilized source of health information. The NOA utilize formal medicine, but may feel excluded in medical decision-making. They desire better access to obstetric care and culturally sensitive medical practice. Providers should ensure appropriate communication to increase healthcare-related comfort of this underserved population.

Partnering With Community-Dwelling Individuals With Diabetes for Health Behavior Change Using Action Plans: An Innovation in Health Professionals Education and Practice.

Health care practitioners support or hinder an individual's attempts to self-manage health behavior. Practitioners must understand an individual's health needs and goals to effectively partner for behavior change. Self-management support (SMS) promote efforts toward positive health behavior change. Practitioners need training to provide effective SMS, beginning with their formal education. The purpose of this educational practice project was to integrate an evidence-based intervention (SMS using action plans) into a nursing curriculum. Three sequential steps included (1) providing foundational SMS education, (2) SMS application with students' personal action plans, and (3) implementing SMS with community-dwelling individuals with diabetes. Students (n = 130) partnered with participants (n = 85), developing short- (n = 240) and long-term (n = 99) action plans during home visits. The average baseline Diabetes Empowerment Scale score measuring participant's perceived psychosocial diabetes management self-efficacy was 4.3 (1-5 scale, SD = 0.51, n = 83). Most common short-term actions related to physical activity (n = 100, 42%) and healthy eating (n = 61, 25%). Average participant confidence level was 7.7 (SD = 1.9, 0-10 scale). Short-term goal evaluation (n = 209) revealed 66% (n = 137) were met more than 50% of the time. Both participants (99%) and students (99%) expressed satisfaction with home visit and action plan experiences. This teaching-learning experience is replicable and applicable to any professional health care student.

Identifying and addressing social determinants of health to improve patient-centered care.

The purpose of this clinical improvement project was to instill a streamlined process of identifying social determinants of health (SDOH) in our clinic's diverse patient population and provide resources that address these barriers to health and well-being. At each clinic visit, patients self-identified SDOH through an easy-to-use Social Assessment Form. Using an online database, Community Relay (CR), providers had access to location-based community resources. In addition to accomplishing the above-mentioned goals, we were left with a more well-rounded understanding of our patients. Unique struggles were identified and barriers to care were revealed, allowing for more patient-centered medical care.

Point-of-Care Ultrasound and Procedural Instruction in the Family Medicine Clerkship: A CERA Study.

BACKGROUND AND OBJECTIVES: Point-of-care ultrasound (POCUS) education has become a mainstay in resident education in multiple specialties, including family medicine (FM), but literature regarding the use of POCUS during clinical medical student education is lacking. The purpose of this study was to investigate whether and how POCUS education is conducted in FM clerkships in the United States and Canada and how it compares to more traditional FM clinical procedural instruction. METHODS: As part of the 2020 Council of Academic Family Medicine's Educational Research Alliance survey of FM clerkship directors, we surveyed clerkship directors in the United States and Canada about whether and how POCUS education, as well as other procedural instruction in their institutions and FM clerkships, was conducted. We included questions regarding POCUS and other procedural use by preceptors and faculty. RESULTS: We found that 13.9% of clerkship directors reported structured POCUS education during clerkship, while 50.5% included other procedural training. The survey revealed that 65% of clerkship directors felt that POCUS was an important component of FM, but this was not a predictor of POCUS use in personal or preceptor practice nor of its inclusion in FM clerkship education. CONCLUSIONS: Structured POCUS education is a rare component of FM clerkship education; while more than half of clerkship directors felt that POCUS was important for FM, few used it personally or included it in clerkship education. As POCUS continues to be integrated into medical education in FM, the clerkship may represent an opportunity to expand POCUS exposure for students.

Innovative Use of the Health Status Questionnaire-12 for Individual and Population Health.

PURPOSE: Demonstrate how self-reported health (SRH) percentile ranks can be used in public health and clinical practice for better interpretable data. METHODS: Secondary analysis was completed to standardize Health Status Questionnaire-12 Version 2.0 (HSQ-12) scores. The HSQ-12 is a multi-item measure of SRH, with a Total Health Status Scale (THSS) and two subscales, Physical Health Status Scale (PHSS) and Mental Health Status Scale (MHSS). The sample included adult (19 and older) participants in Medicaid, including a normed sample (n=7,110) and population cohorts of midlife women (n=417) and pregnant women (n=1,888). RESULTS: Normed percentile data for HSQ-12 using the Medicaid sample were calculated and populations of midlife and pregnant women were compared with the normed percentile ranks. Results illustrate differences in percentile rank scores for the various population cohorts. CONCLUSIONS: This innovative strategy has the potential to lead to decisions that may positively influence health policies, outcomes, and lower health costs.

Improving Student Understanding of Academic Assessment Vocabulary Words Using Visual Cues: A Collaborative Effort.

Many students have difficulty understanding terms from the academic register such as "analyze," "discuss," and "compare." This issue may be exacerbated for some Native American students, especially those who live on reservations with limited exposure to mainstream cultures. In this community-based participatory research project, academic investigators partnered with educators and community members from Native communities in Nebraska and South Dakota to expand students' academic vocabulary and improve student achievement. Together, we formed a team in which community members collaborated with academic investigators to develop word-wall cards incorporating dual-coding theory-that is, combining visual and verbal cues-to help students understand academic vocabulary words. Paivio's dual-coding theory postulates that verbal and visual information are encoded in separate but interconnected pathways and that concepts encoded via both pathways are more easily remembered. Accordingly, presenting information using multiple mediums, such as graphs, photographs, or demonstrations, may enhance learning. These cards were shared with community educators who used them in their classrooms. We present evidence that incorporating these multimodal tools into classrooms may improve students' understanding of academic vocabulary. Through this partnership, educators in Native American communities were able to represent their lived experiences. Teachers and administrators in Native American and non-Native classrooms could easily partner with other experts to incorporate similar innovations in their own schools and classrooms.

Computerized Tomography derived psoas muscle indices in a healthy young population in the United States.

Objective: Psoas muscle metrics from diagnostic computerized tomography (CT) scans are emerging as clinically relevant biomarkers. Most muscle metrics from the US population are from older cohorts with co-morbidities. Published reports from a young or healthy population in the United States on psoas muscle metrics optimized for age, body mass index (BMI), and sex are lacking. This study determines the psoas muscle index (PMI) and psoas muscle density (PMD) for a normal young Midwestern US population. Methods: Retrospective cross-sectional analysis of pre-existent abdominal non-contrast CT scans from a young (19-40 years old), Midwestern, predominately Caucasian population was conducted within Aquarius iNtuition software automatically after manual identification of the psoas muscle. Electronic medical records provided access to subject data and archived CT scans were reviewed. Results: From 193 (45 male, 148 female) CT scans, for males, PMI was 5.9 cm2/m2 (SD=1.7) and PMD 48.4 HU (SD=5.5); for females PMI was 5.4 cm2/m2 (SD=1.4) and PMD 48.18 HU (SD=5.5). BMI was significantly correlated with PMI and PMD for both men (p<0.001, p<0.001 respectively) and women (p<0.001, p<0.001 respectively). Conclusion: Psoas muscle metrics are newly generated for PMI and PMD in a healthy population, allowing for future comparison studies determining muscle status.

Utilizing a Community Dance to Hold STD Testing for Chlamydia and Gonorrhea in High-Risk Adolescents.

INTRODUCTION: Sexually transmitted diseases (STDs) in adolescents are a major public health concern, particularly in underserved communities. While STD screening is recommended by the United States Preventive Services Task Force, limited access remains one of a number of barriers. Community-based approaches may provide greater access and enhance screening rates. This study occured in a nationally recognized hot spot for STDs. We used a unique approach of hosting supervised dances at a community venue, during which free STD screening was offered at an attached health care clinic. METHODS: A series of six Friday night dances was held at one community center sponsored by a nonprofit, girl-focused organization from 2018 to 2019. Dance participants could access an on-site health clinic for self-collected screening for chlamydia and gonorrhea. Treatment was provided for detected STDs. STD screening was also available to area youth at the on-site clinic during regular daytime clinic hours. RESULTS: A total of 118 adolescents were screened during the school year, and were predominantly female (88.13%) and African American (85.6%). More than half of the total STD screenings (51.7%) were administered during the dances, doubling the total number of STD screenings when compared to those administered during regular clinic hours. A significantly younger cohort were screened at the dances (mean age 14.8 years) compared to those screened at the regular clinic (mean age of 18.9 years). CONCLUSION: A youth-centric event utilizing community resources can be used to facilitate and enhance screening rates for STDs in youth in an underserved, high-risk community.

The Effect of Insurance on Appropriate Hospital Discharge Antibiotics for Patients With Staphylococcus aureus Bacteremia.

BACKGROUND: Inappropriate antimicrobial therapy of Staphylococcus aureus bacteremia (SAB) is associated with worsened outcomes. The impact of insurance coverage on appropriate selection of antibiotics at discharge is poorly understood. METHODS: We used a retrospective cohort design to evaluate whether patients with SAB at a large academic medical center over 2 years were more likely to receive inappropriate discharge antibiotics, depending on their category of insurance. Insurance was classified as Medicare, Medicaid, commercial, and none. Logistic regression was used to determine the odds of being prescribed inappropriate discharge therapy. RESULTS: A total of 273 SAB patients met inclusion criteria, with 14.3% receiving inappropriate discharge therapy. In the unadjusted model, there was 2-fold increased odds of being prescribed inappropriate therapy for Medicare, Medicaid, and no insurance, compared with commercial insurance, respectively (odds ratio [OR], 2.08; 95% CI, 1.39-3.13). After controlling for discharge with nursing assistance and infectious diseases (ID) consult, there were 1.6-fold increased odds (OR, 1.57; 95% CI, 0.998-2.53; P = .064) of being prescribed inappropriate therapy for Medicare, Medicaid, and no insurance, compared with commercial insurance, respectively. We found that being discharged home without nursing assistance resulted in 4-fold increased odds of being prescribed inappropriate therapy (OR, 4.16; 95% CI, 1.77-9.77; P < .01), and failing to consult an ID team resulted in 59-fold increased odds of being prescribed inappropriate therapy (OR, 59.2; 95% CI, 11.4-306.9; P < .001). CONCLUSIONS: We found strong evidence that noncommercial insurance, discharging without nursing assistance, and failure to consult ID are risk factors for being prescribed inappropriate antimicrobial therapy for SAB upon hospital discharge.

Comprehensive Obesity Education for Family Medicine Residents.

BACKGROUND: Family medicine residents receive limited education on obesity management and obesity bias. Weight stigmatization is prevalent in primary care providers and trainees, and early mitigation is critical to optimize patient-centered care. Recent Provider Competencies for the Prevention and Management of Obesity include obesity bias. This report is intended to fill a current gap in obesity education for family medicine residents. METHODS: An interprofessional obesity teaching half day for family medicine residents incorporated the Provider Competencies and focused on five modules that addressed complexities of obesity and its clinical management. The obesity bias module focused on both explicit and implicit bias, assessment of implicit bias, preferential language usage, and mitigation strategies. An obesity-simulation empathy suit was available, and a public health expert described successful obesity care in a patient-centered medical home. Family medicine residents were surveyed prior to, immediately after the half-day of obesity teaching, and 15 months later. RESULTS: Survey results indicated 39.3% of residents had no previous biopsychosocial obesity education. Residents believed the content moderately (68.8%) or mostly (12.5%) impacted their approach to working with patients with obesity. Residents' comfort in working with patients with obesity as well as their perceived understanding of their own biases increased immediately after the intervention and was sustained 15 months later. CONCLUSIONS: Our results suggest that a half day of obesity teaching can have a positive and sustained impact on family medicine residents. Additionally, this educational experience allowed for greater individual awareness building and insight regarding implicit bias. Such education for family medicine residents fills an identified gap in obesity education.

From professional silos to interprofessional education: campuswide focus on quality of care.

OBJECTIVES: The Institute of Medicine called for the integration of interprofessional education (IPE) into health professions curricula, in order to improve health care quality. In response, we developed, implemented, and evaluated a campus wide IPE program, shifting from traditional educational silos to greater collaboration. METHODS: Students (155) and faculty (30) from 6 academic programs (nursing, medicine, public health, allied health, dentistry, and pharmacy) engaged with a university hospital partner to deliver this program. The content addressed principles of IPE, teamwork development and 2 common quality care problems: hospital-acquired infections and communication errors. Pre-/post-surveys, the Readiness for Interprofessional Learning Scale, and the Interprofessional Education Perception Scale, were used for descriptive assessment of student learning. RESULTS: Students demonstrated increased understanding of health care quality and interprofessional teamwork principles and reported positive attitudes toward shared learning. While responses to the Readiness for Interprofessional Learning Scale grew more positive after the program, scores on the Interprofessional Education Perception Scale were more homogeneous. Both students and faculty highly evaluated the experience. CONCLUSION: This program was a first step in preparing individuals for collaborative learning, fostering awareness and enthusiasm for IPE among students and faculty, and demonstrating the feasibility of overcoming common barriers to IPE such as schedule coordination and faculty buy-in.

Sugar-Sweetened Beverage Intake in a Rural Family Medicine Clinic.

BACKGROUND: Sugar-sweetened beverages (SSBs) are a major source of calories, and are associated with adverse health outcomes. Because the majority of studies are undertaken in urban areas, the rural intake of SSB presents a significant gap in current knowledge. The objective of our study was to assess SSB intake in a rural primary care clinic. METHODS: The Beverage Intake Questionnaire is a 15-item self-reported questionnaire and has been extensively validated to assess habitual SSB consumption. The survey was administered to adult primary care clinic patients presenting for routine care over a 6-week period at a clinic in a rural central Nebraska community (population < 1,000). RESULTS: Survey participants (n = 121) were primarily white with an average age of 61 years (SD = 18.0) and an average body mass index (BMI) of 29.9 kg/m2 (SD = 7.5). Participants consumed an average of 1.05 SSBs per day (SD = 1.3), and 33.5% of respondents consumed one or more SSBs per day. The average daily caloric intake from SSBs was 153 Kilocalories (Kcals) compared the national average intake of 145 Kcals. The most commonly consumed caloric beverages, based on Kilocalories consumed, were 100% juice and regular soda. SSB consumption was not related to with BMI. DISCUSSION: In a rural primary care clinic, the daily consumption of SSB by patients was found to be a noteworthy source of calories, with no significant difference in consumption across BMI categories. Mitigation of SSB consumption by rural primary care clinicians is imperative for optimizing health.

Sugar-Sweetened Beverage Intake Assessment in a Family Medicine Residency Clinic.

INTRODUCTION: Sugar-sweetened beverages (SSBs) are a major source of added calories in the American diet, with significant adverse health outcomes. However, intake of SSBs is not commonly assessed in the clinical setting. In some populations with health disparities there is a higher consumption of caloric beverages, contributing to increased cardiometabolic risk. Family medicine residency clinics often provide services for the underserved population, and may encounter additional barriers in nutritional assessment. METHODS: Our study, conducted at a residency clinic in Omaha, Nebraska, utilized the abbreviated Beverage Intake Questionnaire 15 (BEVQ-15). We surveyed 310 patients over a 3-month period. RESULTS: Consumption of SSBs in our sample was significantly higher than that of the nonclinic population of Nebraska (P<0.001). Fifty-six percent of resident clinic respondents reportedly consumed at least one SSB daily, resulting in an average intake of 244 kilocalories. Intake was significantly higher in males, younger patients, those with lower socioeconomic status, and Latinos. While the majority of the study population was obese, there was no direct correlation between weight and SSB intake. The survey required less than 3 minutes to complete. Future interventions may focus on reduction of SSB intake and promotion of water consumption. CONCLUSIONS: Assessment of SSB intake in a family medicine residency clinic can be easily conducted, providing opportunities for clinical providers to suggest patient-specific modifiable behaviors. As the obesity epidemic continues to progress, point-of-care intervention to reduce SSB consumption may help reduce cardiometabolic risk and improve health outcomes.

Preceptorship rurality does not affect medical students' shelf exam scores.

OBJECTIVE: This study's objective was to determine whether junior medical students' end-of-rotation shelf exam scores varied by the preceptorship county's rurality. METHODS: Student learning during rural preceptorship experiences, 1999 to 2005, was assessed using the students' scores on the National Board of Medical Examiners family medicine subject examination. Rurality was measured using both population density and the rural-urban continuum (RUC) codes. RESULTS: Exam scores were collected between January 1999 and May 2005 for 734 students. Mean scores did not vary significantly by rurality, although they did vary significantly by semester. Test scores of students in rural locations were not statistically significantly different from those of students in urban preceptorships. CONCLUSIONS: Students assigned to preceptorships in rural locations scored at the same levels as students in urban preceptorships. The finding that there were no differences in medical students' exam scores based on the rurality of their family medicine preceptorship site indicates a substantial degree of educational equivalency between urban and rural preceptorships.

Physicians' perspectives on caring for cognitively impaired elders.

PURPOSE: This study aims to develop an in-depth understanding of the issues important to primary care physicians in providing care to cognitively impaired elders. DESIGN AND METHODS: In-depth interviews were conducted with 20 primary care physicians. Text coded as "cognitive impairment" was retrieved and analyzed by use of grounded theory analysis techniques. RESULTS: A patient's impaired ability to provide an accurate history and to participate in self-care hindered the usual process of care, often resulting in greater medical uncertainty and feelings of inadequacy and frustration for the physician. Shifting the goal of care from "curing" the patient's illness to "caring" for the patient's quality of life was also problematic. The doctor-patient relationship changed dramatically as others became involved in care, often with attendant ethical dilemmas related to patient autonomy and the locus of decision making. Many physicians described a deep sense of loss and grief as the personhood of patients faded. The increased complexity and prominent social and emotional issues were difficult to manage in the context of the current model of practice. IMPLICATIONS: Profound changes occur in the process of care with cognitively impaired patients. The increased complexity mandates an expanded model of care that addresses the prominent psychosocial and ethical aspects of care as well as the medical ones.