Outcomes assessment of case-based writing exercises in a veterinary clinical pathology course.

Our second-year core clinical pathology course uses free-response case-based learning exercises in an otherwise traditional lecture or laboratory course format to augment the development of skills in application of knowledge and critical thinking and clinical reasoning. We previously reported increased learner confidence accompanied by perceived improvements in understanding and ability to apply information, along with enhanced feelings of preparedness for examinations that students attributed to the case-based exercises. The current study prospectively follows a cohort of students to determine the ability of traditional multiple-choice versus free-response case-based assessments to predict future academic performance and to determine if the perceived value of the case-based exercises persists through the curriculum. Our data show that after holding multiple-choice scores constant, better performance on case-based free-response exercises led to higher GPA and better class rank in the second and third years and better class rank in the fourth year. Students in clinical rotations reported that the case-based approach was superior to traditional lecture or multiple-choice exam format for learning clinical reasoning, retaining factual information, organizing information, communicating medical information clearly to colleagues in clinical situations, and preparing high quality medical records. In summary, this longitudinal study shows that case-based free-response writing assignments are efficacious above and beyond standard measures in determining students' GPAs and class rank and in students' acquisition of knowledge, skills, and clinical reasoning. Students value these assignments and overwhelmingly find them an efficient use of their time, and these opinions are maintained even two years following the course.

Postpartum depression screening at well-child visits: validity of a 2-question screen and the PHQ-9.

PURPOSE: Postpartum depression affects up to 22% of women who have recently given birth. Most mothers are not screened for this condition, and an ideal screening tool has not been identified. This study investigated (1) the validity of a 2-question screen and the 9-item Patient Health Questionnaire (PHQ-9) for identifying postpartum depression and (2) the feasibility of screening for postpartum depression during well-child visits. METHODS: Study participants were English-literate mothers registering their 0- to 1-month-old infants for well-child visits at 7 family medicine or pediatric clinics. They were asked to complete questionnaires during well-child visits at 0 to 1, 2, 4, 6, and 9 months postpartum. Each questionnaire included 2 depression screens: the 2-question screen and the PHQ-9. The mothers also completed the depression component of the Structured Clinical Interview for DSM-IV (SCID) initially, and again at a subsequent interval if either screening result was positive for depression. RESULTS: The response rate was 33%. Of the 506 women who participated, 45 (8.9%) had major depression (ie, they had a positive result on the SCID). The screen sensitivities/specificities over the course of the study were 100%/44% with the 2-question screen, 82%/84% with the PHQ-9 using simple scoring, and 67%/92% with the PHQ-9 using complex scoring. In addition, the corresponding values for the first 2 items of the PHQ-9 (ie, the 2-item Patient Health Questionnaire or PHQ-2) were 84%/79%. Some 38% of women completed their 2- to 6-month questionnaires during well-child visits; the rest completed them by mail (29%) or telephone (33%). CONCLUSIONS: The 2-question screen was highly sensitive and the PHQ-9 was highly specific for identifying postpartum depression. These results suggest the value of a 2-stage procedure for screening for postpartum depression, whereby a 2-question screen that is positive for depression is followed by a PHQ-9. These screens can be easily administered in primary care clinics; feasibility of screening during well-child visits was moderate but may be better in clinics using a mass-screening approach.

Predictors of mothers' postpartum body dissatisfaction.

PURPOSE: To investigate changes in mothers' body dissatisfaction from delivery to 9 months postpartum, and the relationship of postpartum body dissatisfaction to weight, other health, and social characteristics. METHODS: In this prospective longitudinal study, 506 mothers completed surveys at 0-1 and 9 months postpartum. Postpartum changes in body dissatisfaction and weight were evaluated by paired t-tests, and predictors of postpartum body dissatisfaction were identified by stepwise multiple regression analysis. RESULTS: Mothers' body dissatisfaction increased significantly from 0-1 to 9 months postpartum (mean scores of 15.2 and 18.2, respectively, p < .001). Although women lost an average of 10.1 pounds (sd = 16.3) or 4.6 kg. (sd = 7.4) between 0-1 and 9 months postpartum (p < .001), their weight at 9 months postpartum remained an average of 5.4 pounds (sd = 15.6) or 2.5 kg (sd = 7.1) above their pre-pregnancy weights (p < .001). Body dissatisfaction at 9 months postpartum was associated with overeating or poor appetite, higher current weight, worse mental health (SF-36 Mental Health scale), race other than black, bottle-feeding (vs. breastfeeding), being single (vs. married), and having fewer children. CONCLUSIONS: Mothers' body satisfaction worsened from 1 to 9 months postpartum, and 9-month body dissatisfaction was associated with eating/appetite abnormalities, greater weight, worse mental health, non-black race, non-breastfeeding status, and fewer immediate family relationships. Given these relationships, it is important to educate women about expected postpartum weight and body changes, and to find ways to enhance mothers' postpartum self-esteem and body satisfaction.

Menstrual phase effects on smoking relapse.

AIMS: To examine if menstrual phase affects relapse in women attempting to quit smoking. DESIGN: An intent-to-treat randomized smoking cessation trial where women were assigned to quit smoking in either the follicular (F) or luteal (L) menstrual phase and were followed for up to 26 weeks. They were assessed for relapse by days to relapse and relapse phase to determine if those who begin a quit attempt during the F phase were more successful than those who begin during the L phase. SETTING: Tobacco Use Research Center, University of Minnesota, Minneapolis, Minnesota. PARTICIPANTS: A total of 202 women. MEASUREMENTS: Latency to relapse from continuous and prolonged abstinence, point prevalence, phase of relapse, first slip within the first 3 and 5 days post-quit date, subject completion rates and symptomatology (i.e. withdrawal and craving). FINDINGS: The mean days to relapse from continuous abstinence and relapse from prolonged abstinence for the F group were 13.9 and 20.6 days, respectively, and 21.5 and 39.2 days, respectively, for the L group. Using point prevalence analysis at 14 days, 84% of the F group had relapsed compared with 65% of the L group [chi(2)=10.024, P=0.002; odds ratio (OR) = 2.871, 95% confidence interval (CI), 1.474-5.590]. At 30 days, 86% of the F group relapsed, compared with 66% of the L group (chi(2)=11.076, P=0.001; OR=3.178, 95% CI, 1.594-6.334). CONCLUSION: Women attempting to quit smoking in the F phase had less favorable outcomes than those attempting to quit in the L phase. This could relate to ovarian hormones, which may play a role in smoking cessation for women.

A theoretical, practical, predictive model of faculty and department research productivity.

PURPOSE: Although numerous characteristics impact faculty research productivity, and although researchers have suggested comprehensive theoretical models to explain the relationship between these characteristics and levels of faculty research productivity, few studies have assessed these models. This study tests the ability of the Bland et al. (2002) model-based on individual, institutional, and leadership variables influencing faculty research productivity-to explain individual and group (department) research productivity within the context of a large medical school. METHOD: This study used data from a University of Minnesota Medical School-Twin Cities vitality survey conducted in 2000 that had a response rate of 76% (n = 465 faculty). A statistical software package was used to conduct t tests, logistic regressions, and multiple regressions on these data. RESULTS: The validity of faculty, department, and leadership characteristics identified in the Bland et al. (2002) model were confirmed as necessary for high levels of research productivity. Faculty productivity was influenced more by individual and institutional characteristics; group productivity was more affected by institutional and leadership characteristics. CONCLUSION: The characteristics and groupings (individual, institutional, and leadership) in the Bland et al. (2002) model predict faculty research productivity. Research productivity is influenced by the interaction of the three broad groupings, and it is the dynamic interplay of individual and institutional characteristics, supplemented with effective leadership, that determines the productivity of individuals and departments.

Group visits for Hmong adults with type 2 diabetes mellitus: a pre-post analysis.

Hmong refugees with type 2 diabetes mellitus (DM2) have poor glycemic control. For Hmong adults with DM2, group visits were instituted at a community health center and evaluated for their influence on diabetes management. Pre- and postintervention measures of physical health, mental health, and behavior were collected on 39 participants (64% participation rate). Baseline characteristics and clinical outcomes of 39 group visit participants were compared with 22 Hmong DM2 adults who refused to participate and 216 nonparticipating Hmong DM2 adults from a local diabetes registry. Baseline characteristics were similar among the three groups. Although participants received good medical services and their mental health improved (p < 0.05), clinical outcomes did not significantly improve. Although group visits are feasible for providing medical services for Hmong adults with DM2, clinical outcomes remain outside of recommended targets. Addressing mental health in this population may be necessary before people can institute behavioral changes that improve diabetes management.

One school's strategy to assess and improve the vitality of its faculty.

The authors report how one medical school took an evidence-based, collaborative approach to assessing and improving faculty vitality by building on previous research and including important shareholders (e.g., faculty and administrators). In 1999, the dean and faculty senate asked all full-time faculty (615) at the University of Minnesota Medical School-Twin Cities to complete a survey to (1) identify vitality areas (individual, institutional, or leadership) in which the school was strong and ones that needed improvement, (2) identify strategies for addressing weak areas, and (3) provide a baseline against which to measure the impact of any vitality efforts initiated. The survey was based on features that research studies have found to be associated with academic productivity. Seventy-six percent responded. Summaries of the survey findings were prepared for use at the school level, department level, and special group level (e.g., women, clinical-scholar-track faculty). Three key school-level findings were that (1) there is a disconnect between the stated vision of the school and the departments' visions and actions, (2) there is not enough time for scholarly activity, particularly in the clinical departments, and (3) faculty lack the support of a collegial atmosphere and appreciation for the work they do. In response to the survey's findings every department identified priority faculty needs and initiated tailored development strategies. School-wide strategies were also initiated to address faculty needs common across departments and needs unique to special groups. Together these strategies provide a multi-level, systematic approach to maintaining faculty vitality.

A pilot, open clinical study of depakote in the treatment of cocaine abuse.

The effectiveness of increasing levels of valproic acid on cocaine abstinence was evaluated in an open-label trial of 55 subjects. Significantly lower percentages of individuals with valproate serum levels above 50 mcg/ml reported cocaine use and had less positive urinalyses as compared to those with serum levels less than 50 mcg/ml. The total number of days of cocaine use decreased significantly (p < 0.001) and improved levels of subject functioning were found with increasing serum levels of valproic acid. This pilot study offers confirmation that the divalproex sodium form of valproic acid, when used in sufficient serum levels, may provide an effective pharmacologic adjunct in the management and treatment of cocaine dependency. Copyright 2001 John Wiley & Sons, Ltd.

A randomized controlled trial testing the impact of a support/work-planning intervention on first-time parents' health, partner relationship, and work responsibilities.

The authors randomly assigned 151 couples expecting their first child to a support/work-planning intervention group or a standard prenatal curriculum group. To evaluate the impact of the intervention, they conducted surveys at baseline and 6-months postpartum to assess mental and physical health, partner satisfaction and caring, work time, housework sharing, and satisfaction with housework sharing. They found no significant group differences on postpartum health or work outcomes, although fathers in the experimental group, in contrast to controls, showed a trend toward less postpartum decline in housework sharing. The study identified a tool to help parents plan their postpartum work responsibilities. The tool, as tested in this trial, did not have a significant impact on parents' work behaviors or health outcomes. Further studies are needed to investigate mechanisms to support young parents during their demanding early childbearing years.

Long-term care benefits may reduce end-of-life medical care costs.

Abstract This study explores whether personal care services for functionally dependent or cognitively impaired individuals paid for by a long-term care (LTC) insurance policy can reduce health care utilization and costs at the end of life. This retrospective study uses propensity score matching methodology, hierarchical multiple regression, and Poisson regression to compare 830 decedents who utilized benefits from a voluntary LTC insurance plan ("claimants") to 6860 decedents who never purchased coverage but were similar to claimants on 17 variables, including age, sex, frailty, burden of illness markers, and propensity to have needed LTC services. Claimants using LTC benefits experienced significantly lower health care costs at end of life, including 14% lower total medical costs, 13% lower pharmacy costs, 35% lower inpatient admission costs, and 16% lower outpatient visit costs. They also experienced 8% fewer inpatient admissions and 10% fewer inpatient days. The presence of dementia at the end of life moderated these effects. This study suggests that use of insurance-based LTC services measurably reduces health care expenditures at the end of life. (Population Health Management 2014;17:332-339).

Relating mentor type and mentoring behaviors to academic medicine faculty satisfaction and productivity at one medical school.

PURPOSE: To examine relationships among having formal and informal mentors, mentoring behaviors, and satisfaction and productivity for academic medicine faculty. METHOD: In 2005, the authors surveyed full-time faculty at the University of Minnesota Medical School to assess their perceptions of variables associated with job satisfaction and productivity. This analysis focused on perceptions of mentoring as related to satisfaction with current position and productivity (articles published in peer-reviewed journals [article production] and role as a primary investigator [PI] or a co-PI on a grant/contract). RESULTS: Of 615 faculty, 354 (58%) responded. Satisfied faculty were not necessarily productive, and vice versa. Outcomes differed somewhat for mentor types: Informal mentoring was more important for satisfaction, and formal mentoring was more important for productivity. Regardless of mentor type, the 14 mentoring behaviors examined related more to satisfaction than productivity. Only one behavior-serves as a role model-was significantly, positively related to article production. Although participants reported that formal and informal mentors performed the same mentoring behaviors, mentees were more satisfied or productive when some behaviors were performed by formal mentors. CONCLUSIONS: The results emphasize the importance of having both formal and informal mentors who perform mentoring behaviors associated with satisfaction and productivity. The results provide a preliminary indication that mentor types and specific mentoring behaviors may have different effects on satisfaction and productivity. Despite the differences found for some behaviors, it seems that it is more essential that mentoring behaviors be performed by any mentor than by a specific type of mentor.

An adaptive approach to facilitating research productivity in a primary care clinical department.

Efforts to foster the growth of a department's or school's research mission can be informed by known correlates of research productivity, but the specific strategies to be adopted will be highly context-dependent, influenced by local, national, and discipline-specific needs and resources. The authors describe a multifaceted approach-informed by a working model of organizational research productivity-by which the University of Minnesota Department of Family Medicine and Community Health (Twin Cities campus) successfully increased its collective research productivity during a 10-year period (1997-2007) and maintained these increases over time.Facing barriers to recruitment of faculty investigators, the department focused instead on nurturing high-potential investigators among their current faculty via a new, centrally coordinated research program, with provision of training, protected time, technical resources, mentoring, and a scholarly culture to support faculty research productivity. Success of these initiatives is documented by the following: substantial increases in the department's external research funding, rise to a sustained top-five ranking based on National Institutes of Health funding to U.S. family medicine departments, later-stage growth in the faculty's publishing record, increased research capacity among the faculty, and a definitive maturation of the department's research mission. The authors offer their perspectives on three apparent drivers of success with broad applicability-namely, effective leadership, systemic culture change, and the self-awareness to adapt to changes in the local, institutional, and national research environment.

Problems with a diagnostic depression interview in a postpartum depression trial.

BACKGROUND: Diagnostic and Statistical Manual (DSM) IV-based depression interviews, valued for their diagnostic accuracy, are often considered to be essential for depression treatment trials. However, this requirement can be problematic because of participant burden. The purpose of this article is to describe our experience with the depression component of the Structured Clinical Interview for DSM Disorders (SCID) in a postpartum depression treatment trial. METHODS: In this prospective cohort study of 506 mothers of infants from 7 primary care clinics, participants were asked to complete the depression module of the SCID interview soon after enrollment. They were asked to complete the 9-item Patient Health Questionnaire (PHQ-9) depression survey at 0 to 1, 2, 4, 6, and 9 months postpartum. RESULTS: Forty-five women (8.9%) had a positive SCID interview and 112 (22.1%) had a positive PHQ-9 during 0 to 9 months postpartum. Problems encountered when using the SCID depression interview included (1) lower than expected SCID-based rates of depression diagnosis (8.9%); (2) SCID noncompletion by 75 women (14.8%); SCID noncompleters (vs completers) were younger, poorer, less educated, and more likely to be single and black (vs white); and (3) inconsistent SCID/PHQ-9 results. Nineteen women with moderately severe to severe PHQ-9 score elevations (≥15) had negative SCID scores; all of these women were functionally impaired. More than 90% of women with positive PHQ-9 scores reported some degree of impairment because of their depressive symptoms. CONCLUSIONS: The requirement of a diagnostic depression interview resulted in selection bias and missed opportunities for depression diagnosis; these are problems that detract from the interview's key strength-its diagnostic accuracy. These problems should be considered when electing to use a DSM-IV-based depression interview in research.

Changes in depressive symptoms over 0-9 months postpartum.

OBJECTIVE: To investigate mothers' changes in prevalence of postpartum depression (PPD) symptoms over 0-9 months postpartum and determine which symptoms best distinguish depressed from nondepressed women. METHODS: This was a prospective study of English-literate mothers of newborns, recruited from four family medicine clinics and three pediatric clinics. Mothers completed surveys at 0-1, 2, 4, 6, and 9 months postpartum, and surveys included demographic characteristics, a two-question depression screen, the 9-Item Patient Health Questionnaire (PHQ-9), and other health and work characteristics. RESULTS: There were 506 participants (33% response rate), and 112 (22.1%) had a positive PHQ-9 (score ≥10) at some time within the first 9 months after delivery. The proportion of women with a positive PHQ-9 was greatest at 0-1 month (12.5%), then fell to between 5.0% and 7.1% at 2-6 months, and rose again to 10.2% at 9 months postpartum. Most of the PHQ-9 symptoms differentiated well between depressed and nondepressed women; items that were less discriminating were abnormal sleep, abnormal appetite/eating, and fatigue. Assessment of possible predictors of a change from negative to positive PHQ-9 between 6 and 9 months postpartum revealed only one significant predictor: prior history of depression. CONCLUSIONS: Depressive symptoms in this sample were most frequent at 0-1 month and 9 months postpartum. Most PHQ-9 items differentiated well between depressed and nondepressed mothers; these findings support the use of the PHQ-9 for PPD screening. Future research is needed to confirm our observed secondary peak in depressive symptoms at 9 months postpartum and to investigate possible causes.

Efforts to graduate more primary care physicians and physicians who will practice in rural areas: examining outcomes from the university of Minnesota-duluth and the rural physician associate program.

PURPOSE: To compare practice choices (primary care or specialty) and practice locations (rural or metropolitan) of medical students at the Duluth and Twin Cities (Minneapolis and St. Paul; TC) campuses of the University of Minnesota (UMN). In the early 1970s, Minnesota created two medical education programs at UMN to increase the number of rural and primary care physicians: the first two years of medical school at UMN-Duluth, where the program focuses on recruiting students who will be rural family physicians, and the Rural Physician Associate Program (RPAP) elective, a nine-month, longitudinal immersion experience with a preceptor in a rural community. METHOD: In 2008, the authors analyzed outcomes for four student groups: (1) UMN-Duluth and (2) UMN-TC medical students who participated in RPAP and (3) UMN-Duluth and (4) UMN-TC students who did not participate in RPAP. UMN medical students complete their first two years on either campus; they can apply to RPAP for their third year. Non-RPAP students spend most of their third- and fourth-year rotations in the Twin Cities metropolitan area. RESULTS: The UMN-Duluth and RPAP students were most likely to select a rural location and primary care practice. UMN-TC, non-RPAP students followed national trends, choosing predominantly metropolitan and specialty practices. CONCLUSIONS: RPAP and UMN-Duluth provide significant, complementary educational programs that lead more graduates to choose rural and primary care practices. Efforts across the nation to address the crisis in rural primary care should build on these successful efforts.

Stepped care treatment of postpartum depression: impact on treatment, health, and work outcomes.

PURPOSE: The purpose of this study was to pilot a stepped collaborative care intervention for women with postpartum depression and evaluate health differences between self-diagnosed depressed and nondepressed women. METHODS: Five hundred six mothers of infants from 7 clinics completed surveys at 0 to 1, 2, 4, 6, and 9 months postpartum and a Structured Clinical Interview for DSM-IV (SCID). SCID-positive depressed women were randomized to stepped collaborative care or usual care. Nine-month treatment, health, and work outcomes were evaluated for stepped care women (n = 19) versus control depressed women (n = 20), and self-diagnosed depressed women (n = 122) versus nondepressed women (n = 344). RESULTS: Forty-five women had SCID-positive depression whereas 122 had self-diagnosed depression. For SCID-positive depressed women, the stepped care intervention increased mothers' awareness of their depression diagnosis (100% vs 61%; P = .008) and their receipt of treatment (94% vs 56%; P = .019). Self-diagnosed depressed women (vs nondepressed women) had more depressive symptoms and acute care visits, worse general and mental health, and greater impact of health problems on regular activities. CONCLUSIONS: The stepped care intervention improved women's knowledge of their postpartum depression diagnosis and their receipt of treatment. However, our formal diagnostic procedures missed many women whose depressed mood interfered with their health and function.

Improving the measurement of criminal sexual behavior: the application of randomized responding technique.

Randomized responding technique (RRT), a method for maintaining anonymity, was used with a sample of sexual offenders recruited into a treatment outcome study. Prior to release from incarceration, three groups--those randomly assigned to treatment, those randomly assigned to no-treatment control, and those who refused participation in the treatment study but consented to a prerelease interview--participated in an alternate-questions RRT procedure. This procedure pairs a nonsensitive question with the sensitive question of interest, in this case, the number of prior sex offenses. Respondents answered either the sensitive or nonsensitive question, depending on the results of a randomizing device (roll of dice). The distributions for the nonsensitive questions were highly skewed; therefore, the outliers were removed and RRT estimates calculated. RRT estimates of prior offending (2.20 prior offenses) were significantly higher than officially recorded prior offenses (0.51 prior offenses). The pattern of differences between treatment and control groups were similar in RRT estimates and officially recorded priors, as were the correlations between RRT estimates and other self-report scales. These results provide preliminary evidence that RRT is a useful method for generating reoffending data that are more sensitive than officially recorded offenses and that contain less bias than other self-reports.

Temporal artery temperature measurements do not detect hyperthermic marathon runners.

INTRODUCTION: Exertional heat stroke is a cause of collapse in marathon runners. Rectal temperature (T(rectal)) measurement is the usual method of estimating core temperature in collapsed runners, and temporal artery thermometer (TAT) measurement is untested for field use in marathon runners and other athletes. The objective of this study is to compare TAT measurement with T(rectal) measurement in collapsed marathon runners. METHODS: TAT-500i (Exergen Corp, Wellesley, MA) temperature measurements were obtained using the manufacturer's instruction manual on 60 collapsed marathon runners who had T(rectal) measurements in the finish area medical tent during two consecutive annual races. RESULTS: The TAT temperatures identified only 2 of 17 hyperthermic runners (T(rectal) > 39.4 degrees C (103 degrees F)), a sensitivity of only 0.12, and a Pearson' correlation coefficient of 0.374 (r = 0.14). Among the 17 hyperthermic runners, the correlation of T(rectal) to TAT temperatures was 0.526 (r = 0.28) with a mean +/- SD T(rectal) of 40.7 +/- 0.94 degrees C (105.1 +/- 1.7 degrees F) and a mean +/- SD TAT temperature of 37.4+/- 1.3 degrees C (99.4 +/- 2.4 degrees F). Among the 43 collapsed normothermic runners, there was no correlation between the rectal and the TAT measurements (r = -0.142, P = 0.37). CONCLUSIONS: These findings indicate that there is little association between the temperatures obtained by temporal artery measurement and T(rectal) measurement in collapsed marathon runners and that TAT temperature is unable to identify hyperthermic runners. Based on these findings, TAT measurement should not be used to assess core body temperature or make treatment decisions for marathon runners with potential exertional heat stroke.

Craving, withdrawal, and smoking urges on days immediately prior to smoking relapse.

Rates of smoking relapse remain high, despite the wide availability of cessation aids. Presumably factors such as craving, withdrawal symptoms, and smoking urges are key contributors to relapse, but empirical support for this presumption is not conclusive and is complicated by the high variability in symptoms across individuals and time, as well as by the lack of an absolute symptom threshold for response. Data were analyzed from 137 female smokers, aged 18-40 years, who completed 30 days of a protocol for a longitudinal smoking cessation trial. Subjects were assigned a quit date and followed regardless of subsequent smoking status. At baseline, subjects completed written measures of nicotine craving, withdrawal symptoms, and smoking urges. They also completed these measures daily for 30 days, beginning on their quit date, Scores were standardized within subjects and graphed to identify temporal symptom patterns. A total of 26 women quit smoking and 111 relapsed (at least one cigarette puff). The intensity of subjects' craving, withdrawal, and smoking urges Factors 1 and 2 peaked on the day of relapse by an average of 1.4, 1.1, 1.2, and 1.1 standard deviations, respectively, with symptoms rising during the previous 2-5 days and dropping precipitously over the 2 days subsequent to relapse. Additionally, women who relapsed had higher absolute (unstandardized) symptom scores on their quit day than those who were abstinent for 30 days. These findings imply that escalation of withdrawal symptoms, craving, and smoking urges during a quit attempt may contribute to smoking relapse. Frequent symptom monitoring might be clinically important for relapse prevention.

Recruitment and retention of rural physicians: outcomes from the rural physician associate program of Minnesota.

CONTEXT: Founded in 1971 with state funding to increase the number of primary care physicians in rural Minnesota, the Rural Physician Associate Program (RPAP) has graduated 1,175 students. Third-year medical students are assigned to primary care physicians in rural communities for 9 months where they experience the realities of rural practice with hands-on participation, mentoring, and one-to-one teaching. Students complete an online curriculum, participate in online discussion with fellow students, and meet face-to-face with RPAP faculty 6 times during the 9-month rotation. Projects designed to bring value to the community, including an evidence-based practice and community health assessment, are completed. PURPOSE: To examine RPAP outcomes in recruiting and retaining rural primary care physicians. METHODS: The RPAP database, including moves and current practice settings, was examined using descriptive statistics. FINDINGS: On average, 82% of RPAP graduates have chosen primary care, and 68% family medicine. Of those currently in practice, 44% have practiced in a rural setting all of the time, 42% in a metropolitan setting and 14% have chosen both, with more than 50% of their time in rural practice. Rural origin has only a small association with choosing rural practice. CONCLUSION: RPAP data suggest that the 9-month longitudinal experience in a rural community increases the number of students choosing primary care practice, especially family medicine, in a rural setting.