Institution-Specific Factors Associated With Family Medicine Residency Match Rates.

UNLABELLED: Phenomenon: Existing research provides little specific evidence regarding the association between public and private medical school curricular settings and the proportion of medical students matching into family medicine careers. Institutional differences have been inadequately investigated, as students who match into family medicine are often consolidated into the umbrella of primary care along with those matching in internal medicine and pediatrics. However, understanding medical school contexts in relation to career choice is critical toward designing targeted strategies to address the projected shortage of family physicians. This study examines factors associated with family medicine residency match rates and the extent to which such factors differ across medical school settings. APPROACH: We combined data from a survey of 123 departments of family medicine with graduate placement rates reported to the American Academy of Family Physicians over a 2-year period. Chi-square/Fisher's Exact texts, t tests, and linear regression analyses were used to identify factors significantly associated with average match rate percentages. FINDINGS: The resulting data set included 85% of the U.S. medical schools with Departments of Family Medicine that reported 2011 and 2012 residency match rates in family medicine. Match rates in family medicine were higher among graduates of public than private medical schools-11% versus 7%, respectively, t(92) = 4.00, p < .001. Using a linear regression model and controlling for institutional type, the results indicated 2% higher match rates among schools with smaller annual clerkship enrollments (p  = .03), 3% higher match rates among schools with clerkships lasting more than 3 to 4 weeks (p  = .003), 3% higher match rates at schools with at least 1 family medicine faculty member in a senior leadership role (p  = .04), and 8% lower match rates at private medical schools offering community medicine electives (p < .001, R(2) = .48), F(6, 64) = 9.95, p < .001. Three additional factors were less strongly related and varied by institutional type-informal mentoring, ambulatory primary care learning experiences, and institutional research focus. Insights: Educational opportunities associated with higher match rates in family medicine differ across private and public medical schools. Future research is needed to identify the qualitative aspects of educational programming that contribute to differences in match rates across institutional contexts. Results of this study should prove useful in mitigating physician shortages, particularly in primary care fields such as family medicine.

Predictors of Depression Stigma in Medical Students: Potential Targets for Prevention and Education.

INTRODUCTION: Suicide rates are higher among U.S. physicians than the general population. Untreated depression is a major risk factor, yet depression stigma presents a barrier to treatment. This study aims to identify early career indications of stigma among physicians-in-training and to inform the design of stigma-reduction programs. METHODS: A cross-sectional student survey administered at a large, Midwestern medical school in fall 2009 included measures of depression symptoms, attitudes toward mental health, and potential sources of depression stigma. Principal components factor analysis and linear regression were used to examine stigma factors associated with depression in medical students. RESULTS: The response rate was 65.7%, with 14.7% students reporting a previous depression diagnosis. Most students indicated that, if depressed, they would feel embarrassed if classmates knew. Many believed that revealing depression could negatively affect professional advancement. Factor analyses revealed three underlying stigma constructs: personal weakness, public devaluation, and social/professional discrimination. Students associating personal weakness with depression perceived medication as less efficacious and the academic environment as more competitive. Those endorsing public stigma viewed medication and counseling as less efficacious and associated depression with an inability to cope. Race, gender, and diagnosis of past/current depression also related to beliefs about stigma. Depression measures most strongly predicted stigma associated with personal weakness and social/professional discrimination. CONCLUSIONS: Recommendations for decreasing stigma among physicians-in-training include consideration of workplace perceptions, depression etiology, treatment efficacy, and personal attributes in the design of stigma reduction programs that could facilitate help-seeking behavior among physicians throughout their career.

Resident Perceptions of Giving and Receiving Peer-to-Peer Feedback.

BACKGROUND: Peer feedback is increasingly being used by residency programs to provide an added dimension to the assessment process. Studies show that peer feedback is useful, uniquely informative, and reliable compared to other types of assessments. Potential barriers to implementation include insufficient training/preparation, negative consequences for working relationships, and a perceived lack of benefit. OBJECTIVE: We explored the perceptions of residents involved in peer-to-peer feedback, focusing on factors that influence accuracy, usefulness, and application of the information. METHODS: Family medicine residents at the University of Michigan who were piloting an online peer assessment tool completed a brief survey to offer researchers insight into the peer feedback process. Focus groups were conducted to explore residents' perceptions that are most likely to affect giving and receiving peer feedback. RESULTS: Survey responses were provided by 28 of 30 residents (93%). Responses showed that peer feedback provided useful (89%, 25 of 28) and unique (89%, 24 of 27) information, yet only 59% (16 of 27) reported that it benefited their training. Focus group participants included 21 of 29 eligible residents (72%). Approaches to improve residents' ability to give and accept feedback included preparatory training, clearly defined goals, standardization, fewer and more qualitatively oriented encounters, 1-on-1 delivery, immediacy of timing, and cultivation of a feedback culture. CONCLUSIONS: Residents perceived feedback as important and offered actionable suggestions to enhance accuracy, usefulness, and application of the information shared. The findings can be used to inform residency programs that are interested in creating a meaningful peer feedback process.

A team-based approach to providing asthma action plans.

BACKGROUND: National guidelines for treatment of asthma include recommendations for providing written asthma action plans (AAPs) to improve outcomes through patient self-management. However, AAP completion rates remain limited in practice. METHODS: We developed a team-based approach for the delivery of care to asthma patients in a primary care setting that involved integration of an electronic clinical quality management system and provision of written AAPs by registered nurses. RESULTS: The percentage of patients with AAPs increased after implementation of clinical reminders and nurse-led provision of written AAPs. CONCLUSION: Proper training, use of an electronic clinical reminder system, and enhanced engagement of registered nurses can improve AAP completion rates in a team-based primary care setting.

Applying health information technology and team-based care to residency education.

BACKGROUND AND OBJECTIVES: Training physicians capable of practicing within the Patient-centered Medical Home (PCMH) is an emerging area of scholarly inquiry within residency education. This study describes an effort to integrate PCMH principles into teaching practices within a university-based residency setting and evaluates the effect on clinical performance. METHODS: Using participant feedback and clinical data extracted from an electronic clinical quality management system, we retrospectively examined performance outcomes at two family medicine residency clinics over a 7-year period. Instructional approaches were identified and clinical performance patterns analyzed. RESULTS: Alumni ratings of the practice-based curriculum increased following institution of the PCMH model. Clinical performance outcomes indicated improvements in the delivery of clinical care to patients. Implementation of instructional methodologies posed some challenges to residency faculty, particularly in development of consistent scheduling of individualized feedback sessions. Residents required the greatest support and guidance in managing point-of-care clinical reminders during patient encounters. CONCLUSIONS: Teaching practices that take into consideration the integration of team-based care and use of electronic health technologies can successfully be used to deliver residency education in the context of the PCMH model. Ongoing assessment provides important information to residency directors and faculty in support of improving the quality of clinical instruction.

Developing online learning modules in a family medicine residency.

BACKGROUND AND OBJECTIVES: Online modules offer an opportunity to overcome barriers to educational delivery. Such approaches can require significant investment dependent on the development model used. There is little in the literature on the formative assessment of design and development. Better understanding is needed to determine effective methods of training and supporting faculty authors. METHODS: The purpose of this study was to examine the effectiveness of Web-based modules developed by a Department of Family Medicine in delivering instruction to resident learners and to examine perceptions of the design and development process. Participants included 49 resident learners and 28 faculty and staff members as the development team. Data collection involved use of Web-based surveys, participant observation focus groups, and pretesting/posttesting. Frequency distributions and mean comparisons were used to analyze quantitative data. Participant comments were thematically analyzed. RESULTS: Residents felt that modules met their educational goals and contributed to understanding of core content. Pretest/posttest data showed statistical improvement for a majority of modules. The use of Web authoring software for Web-based learning and scheduling time to work on the modules posed the greatest challenges to module authors. CONCLUSIONS: Formative assessment methods can provide important information to module developers and support staff to shape training, content development, and improve module ease of use, navigation, and content for resident learners.

Depression, stigma, and suicidal ideation in medical students.

CONTEXT: There is a concerning prevalence of depression and suicidal ideation among medical students, a group that may experience poor mental health care due to stigmatization. OBJECTIVE: To characterize the perceptions of depressed and nondepressed medical students regarding stigma associated with depression. DESIGN, SETTING, AND PARTICIPANTS: Cross-sectional Web-based survey conducted in September-November 2009 among all students enrolled at the University of Michigan Medical School (N = 769). MAIN OUTCOME MEASURES: Prevalence of self-reported moderate to severe depression and suicidal ideation and the association of stigma perceptions with clinical and demographic variables. RESULTS: Survey response rate was 65.7% (505 of 769). Prevalence of moderate to severe depression was 14.3% (95% confidence interval [CI], 11.3%-17.3%). Women were more likely than men to have moderate to severe depression (18.0% vs 9.0%; 95% CI for difference, -14.8% to -3.1%; P = .001). Third- and fourth-year students were more likely than first- and second-year students to report suicidal ideation (7.9% vs 1.4%; 95% CI for difference, 2.7%-10.3%; P = .001). Students with moderate to severe depression, compared with no to minimal depression, more frequently agreed that "if I were depressed, fellow medical students would respect my opinions less" (56.0% vs 23.7%; 95% CI for difference, 17.3%-47.3%; P < .001), and that faculty members would view them as being unable to handle their responsibilities (83.1% vs 55.1%; 95% CI for difference, 16.1%-39.8%; P < .001). Men agreed more commonly than women that depressed students could endanger patients (36.3% vs 20.1%; 95% CI for difference, 6.1%-26.3%; P = .002). First- and second-year students more frequently agreed than third- and fourth-year students that seeking help for depression would make them feel less intelligent (34.1% vs 22.9%; 95% CI for difference, 2.3%-20.1%; P < .01). CONCLUSIONS: Depressed medical students more frequently endorsed several depression stigma attitudes than nondepressed students. Stigma perceptions also differed by sex and class year.