Catheterized urine color change.

What caused the abrupt change in color of catheterized urine after several days of Foley catheter placement?

Curricular Recommendations for a National Family Medicine Subinternship: A Qualitative Analysis From Multiple Stakeholders.

BACKGROUND AND OBJECTIVES: The 2011 Alliance for Clinical Education panel recommended the development of a specialty-specific curriculum for all subinternships (sub-Is). A 2019 CERA survey found that 58% of family medicine clerkship directors agreed that a standardized curriculum would be helpful. The goal of this study was to explore attitudes and preferences regarding a national family medicine sub-I curriculum among a broad set of stakeholders. METHODS: Focus groups were conducted with medical students, residents, residency faculty, and undergraduate medical education faculty at the 2020 STFM Conference on Medical Student Education. Focus groups were transcribed, and a qualitative analysis was conducted with participants' responses about the benefits and characteristics of a family medicine sub-I, recommendations for core sub-I skills/objectives, likelihood of using a national curriculum, and preferred student and program evaluation methods. RESULTS: There were four focus groups with a total of 24 participants. The following main themes emerged: the family medicine sub-I has distinctive characteristics from other sub-Is and provides unique benefits for students and residency programs, a standardized curriculum should allow for adaptability and flexibility, and the sub-I evaluation for the students and program should be specific and experience-focused. These themes were classified into specific subthemes. CONCLUSIONS: The stakeholder emphasis on themes of uniqueness, adaptability, and specificity within evaluation will help educators structure a comprehensive framework for national recommendations for the sub-I curriculum. A well-designed family medicine sub-I may provide rigorous educational training for students and may also encourage career commitment to the discipline.

Treatment effect of aspirin for primary prevention does not differ according to baseline ASCVD risk.

SOURCE CITATION: Nudy M, Cooper J, Ghahramani M, et al. Aspirin for primary atherosclerotic cardiovascular disease prevention as baseline risk increases: a meta-regression analysis. Am J Med. 2020;133:1056-64. 32445718.

Forward Feeding in Graduate Medical Education: Results of a National Survey.

BACKGROUND AND OBJECTIVES: "Forward feeding" is defined as the sharing of information regarding learner behaviors and performance outside of formal institutional committee structures. The purpose of this study was to establish baseline opinions and policies of forward feeding in family medicine residency programs. METHODS: Data for this study were obtained as part of the 2015 CERA Program Directors Fall Survey. Program directors indicated whether they felt that faculty should and do engage in forward feeding. Respondents were asked to rate the importance of various types of information about learners (academic performance, clinical performance, professionalism, physical health, and mental health), reasons for promoting, and concerns regarding forward feeding on a 5-point Likert scale. RESULTS: The overall response rate was 49% (227/461). Most agreed that faculty should (87%) and do (83%) engage in forward feeding. Concerns regarding professionalism and clinical performance were reported as most important to share. The most important reason identified for forward feeding was the early identification of struggling residents, followed by the ability to direct teaching to the resident's specific needs, and improving the quality of feedback. Fear of creating bias was the most commonly cited concern for engaging in forward feeding, followed by fear of violating confidentiality and difficulty maintaining confidentiality. Fear of litigation was the least common concern. CONCLUSIONS: Despite concerns, the majority of program directors feel that faculty should and do engage in forward feeding. Our study confirms the importance of clinical performance and professionalism as two important themes of information shared by attendings about residents.

Prostate Cancer Screening: Shared Decision-Making for Screening and Treatment.

Prostate cancer screening has generated immense interest and controversy in recent years. This article evaluates issues in current prostate cancer pathologic patterns, epidemiology, and screening.

Technology Use to Deliver Faculty Development: A CERA Study.

INTRODUCTION: Technology provides a platform to help address individualized training needs for community preceptors who are separated from the campus and pressured to achieve clinical productivity goals. This study explores technology use and support for delivering faculty development to community preceptors. METHODS: This cross-sectional study was part of the 2017 Council of Academic Family Medicine's (CAFM) Educational Research Alliance (CERA) annual survey of family medicine clerkship directors in the United States and Canada. RESULTS: The majority of respondents (n=62, 68.9%) agreed or strongly agreed that "using technology is critical to the successful delivery of faculty development to community preceptors." Only one-third (n=31) agreed or strongly agreed that their institution offers them adequate support to create and deliver technology-mediated faculty development or offers adequate support to community preceptors for accessing and using technology. CONCLUSIONS: Clerkship directors need institutional support to provide effective faculty development to preceptors via technology. The opportunity exists for institutions, national organizations, and professions to collaborate across disciplines and health professions on technology-based faculty development to support a level of quality and engagement for faculty development that is consistent with the levels we bring to student education.

Institutional NIH Research Funding and a Culture of Support for Family Medicine-Their Relationship to Family Medicine Specialty Choice.

BACKGROUND AND OBJECTIVES: The United States suffers from a low proportion of medical students pursuing family medicine (FM). Our objective was to examine institutional characteristics consistent with a focus on National Institutes of Health (NIH) research, institutional support for FM education, and the proportion of medical students choosing FM. METHODS: The 2015 CERA Survey of Family Medicine Clerkship Directors was merged with institutional NIH funding data from 2014 and medical student specialty choice in 2015. Institutional educational support was operationalized as (1) clerkship director's perception of medical school environment toward FM, and (2) amount of negative comments about FM made by faculty in other departments. The outcome was the percentage of students selecting FM. Bivariate statistics were computed. RESULTS: As NIH funding increases, the proportion of students entering FM decreases (r=-.22). Institutions with higher NIH funding had lower clerkship director perceptions of medical school support toward FM (r=-.38). Among private institutions, the negative correlation between NIH funding and the proportion of students entering FM strengthens to r=-.48, P=.001. As perceptions of support for FM increase, the proportion of students entering FM increase (r=.47). Among private schools, perceptions of support toward family medicine was strongly positively correlated with the proportion of students entering FM (r=.72, P=.001). CONCLUSIONS: Higher institutional NIH funding is associated with less support for FM and lower proportions of students choosing FM. These issues appear to be even more influential in private medical schools. Understanding how to integrate the goals of NIH-level research and increasing primary care workforce so that both can be achieved is the next challenge.

Creating a Centralized Infrastructure to Facilitate Medical Education Research.

PURPOSE: Building research capacity and increasing scholarly productivity are identified needs of the specialty of family medicine. The Accreditation Council for Graduate Medical Education (ACGME) has increased the scholarly requirements for residency programs, placing even more pressure on faculty to be productive in the scholarly realm. The Council of Academic Family Medicine Educational Research Alliance (CERA) was created by volunteer members of the specialty with shared interests in overcoming barriers and increasing scholarly production. METHODS: CERA has developed the infrastructure and expertise to regularly conduct omnibus surveys of key family medicine educational leaders. Proposals are centrally collected and competitively chosen. The omnibus survey process includes collaboration with experienced mentors, centralized institutional review board clearance, pilot testing, and centralized data collection. The survey results are disseminated back to research teams for presentation and publication of the findings. RESULTS: To date, over 115 research teams have had their projects included in CERA omnibus surveys. Projects have been led by research teams from across the country and with a wide variety of research experience. This collaborative work has resulted in more than 75 scientific presentations and over 55 peer-reviewed papers in the medical literature. The raw data are now available online and serve as a repository for future secondary analysis and as an educational resource. CONCLUSIONS: The CERA infrastructure has allowed a large number of research teams to conduct meaningful scholarship at a fraction of the typical cost in terms of time and energy. CERA has expanded family medicine research by removing barriers for teams with limited experience or resources.

Text Messaging as a Teaching Tool in a Family Medicine Clerkship Rotation.

INTRODUCTION: Today's learners use multiple forms of social communication, such as text messaging, that offer a promising teaching tool for medical education. The purpose of this study was to evaluate a diabetes care curriculum delivered through text messages for third-year medical students on a rural family medicine clerkship. METHODS: A pilot study of 119 participants were compared in a parallel group randomized controlled trial evaluating medical student learning and satisfaction with text messages throughout rotation compared to an email with the same content in their first week of rotation. Participants completed a 10-question multiple-choice test and six survey questions upon completing the rotation. The primary outcome was a difference between test scores among the two groups, and student satisfaction with the educational intervention was a secondary outcome. RESULTS: A total of 85 participants successfully completed the study protocol (34 text messages and 51 email) and were included in a per protocol analysis. The average number of correct responses per test was 3.32 (SD 1.29) in the texting group and 3.69 (SD 1.53) in the email group (P=0.259). Student satisfaction with text messages was 3.68 (SD 0.87) compared to email at 2.02 (SD 0.95) when rating the educational intervention on a 1 to 5 Likert scale (1=poor, 3=average, and 5=excellent). CONCLUSIONS: Participant knowledge on a challenging posttest was not improved with text messages compared to an email in this pilot study. Satisfaction with text messages was primarily positive. Further study is needed to determine the effectiveness of this content delivery method.

The role of Balint group training in the professional and personal development of family medicine residents.

This paper presents a study based on the participation of PGY2 and PGY3 family medicine residents in Balint seminars that occurred twice monthly for 24 months. Balint groups were cofacilitated by leader pairs experienced with the Balint method. Prior to residency graduation, 18 of 19 eligible resident physicians (94.5%) completed 30- to 60-min semistructured interviews conducted by a research assistant. Resident physicians were told that these individual interviews concerned "…how we teach communication in residency." The deidentified transcripts from these interviews formed the raw data that were coded for positive (n = 9) and negative (n = 3) valence themes by four faculty coders utilizing an iterative process based on grounded theory. The consensus positive themes included several elements that have previously been discussed in published literature concerning the nature of Balint groups (e.g., being the doctor that the patient needs, reflection, empathy, blind spots, bonding, venting, acceptance, perspective taking, and developing appreciation for individual experiences). The negative themes pointed to ways of possibly improving future Balint offerings in the residency setting ( repetitive, uneasiness, uncertain impact). These findings appear to have consistency with seminal writings of both Michael and Enid Balint regarding the complex nature of intrapsychic and interpersonal skills required to effectively manage troubling doctor-patient relationships. The implications of findings for medical education (curriculum) development as well as future research efforts are discussed.

Untapped Potential: Performance of Procedural Skills in the Family Medicine Clerkship.

BACKGROUND AND OBJECTIVES: While family medicine residency directors have expressed concern about low procedural skills proficiency among incoming residents, curricular recommendations do not provide widely accepted guidance. This study was designed to describe requirements and experiences in procedural skill training during the family medicine clerkship and test the hypothesis that more rural placements may support this training. METHODS: The survey was conducted as part of the CAFM Educational Research Alliance (CERA) Family Medicine Clerkship Director (CD) 2013 survey. All Liaison Committee on Medical Education (LCME)-accredited medical schools in the US and Canada with a family medicine educator as family medicine or primary care CD were surveyed. CDs answered questions about clerkship structure and procedure experience and requirements for students. Choosing from a list of procedures, respondents detailed how often students perform specific skills during a rotation. RESULTS: The response rate was 73% (94 out of 129). Thirty-six procedures were performed during the family medicine clerkship. Of the procedures performed at least once, the most common were Pap test (57.1%), vaginal swab (42.9%), ECG recording (41.9%), urinalysis (40.0%), and throat swab (39.0%). Of the procedures performed more than three times, the most common were Pap test (21.0%) and sterile technique (20.0%). Learners in rural rotations were more likely to perform a range of procedures. CONCLUSIONS: Though exposed to a wide range of procedures during the family medicine clerkship, students did not often repeat procedures. Creation of a core list of procedures and taking better advantage of rural placements may improve procedural skill training in the family medicine clerkship.

Medical Student Teaching and Recruiting: 50 Years of Balancing Two Educational Aims.

BACKGROUND: Family medicine (FM) undergraduate medical educators have had two distinct missions, to increase the knowledge, skills, and attitudes of all students while also striving to attract students to the field of family medicine. A five decade literature search was conducted gathering FM curricular innovations and the parallel trends in FM medical student interest. Student interest in FM had a rapid first-decade rise to 14%, a second 1990's surge, followed by a drop to the current plateau of 8-9%. This falls far short of the 30-50% generalist benchmark needed to fill the country's health care needs. Curricular innovations fall into three periods: Charismatic Leaders & Clinical Exposures (1965-1978), Creation of Clerkships of FM (1979-1998) and Curricular Innovations (1998-present). There is good evidence that having a required third-year clerkship positively impacts student interest in the field, however there is little research regarding the recruitment impact of specific clerkship curricula. Other tools associated with student interest include programming geared towards primary care or rural training and extracurricular opportunities such as FM Interest Groups. Strategic plans to improve the primary care work force should focus funding and legislative efforts on effective methods such as: establishing and maintaining FM clerkships, admitting students with rural and underserved backgrounds or primary care interest, developing longitudinal primary care tracks, and supporting extracurricular FM activities. Rigorous research is needed to assess how best to utilize limited educational resources to ensure that all students graduate with a core set of FM competence as well as an increased FM matriculation.

Faculty Development for Medical School Community-Based Faculty: A Council of Academic Family Medicine Educational Research Alliance Study Exploring Institutional Requirements and Challenges.

PURPOSE: Community-based faculty play a large role in training medical students nationwide and require faculty development. The authors hypothesized that positive relationships exist between clerkships paying preceptors and requiring faculty development, and between protected clerkship directors' time and delivering face-to-face preceptor training, as well as with the number or length of community-based preceptor visits. Through under standing the quantity, delivery methods, barriers, and institutional support for faculty development provided to community-based preceptors teaching in family medicine clerkships, best practices can be developed. METHOD: Data from the 2015 Council of Academic Family Medicine's Educational Research Alliance survey of Family Medicine Clerkship Directors were analyzed. The cross-sectional survey of clerkship directors is distributed annually to institutional representatives of U.S. and Canadian accredited medical schools. Survey questions focused on the requirements, delivery methods, barriers, and institutional support available for providing faculty development to community-based preceptors. RESULTS: Paying community-based preceptors was positively correlated with requiring faculty development in family medicine clerkships. The greatest barrier to providing faculty development was community-based preceptor time availability; however, face-to-face methods remain the most common delivery strategy. Many family medicine clerkship directors perform informal or no needs assessment in developing faculty development topics for community-based faculty. CONCLUSIONS: Providing payment to community preceptors may allow schools to enhance faculty development program activities and effectiveness. Medical schools could benefit from constructing a formal curriculum for faculty development, including formal preceptor needs assessment and program evaluation. Clerkship directors may consider recruiting and retaining community-based faculty by employing innovative faculty development delivery methods.

Balint groups in family medicine residency programs: a follow-up study from 1990--2010.

BACKGROUND AND OBJECTIVES: Balint groups have been part of residency education for decades. This study updates our understanding of the organization, purpose, and leadership of Balint groups within US family medicine residency programs. METHODS: Accreditation Council for Graduate Medical Education (ACGME)-approved family medicine residency training programs (n=453) were contacted to complete a questionnaire, similar to ones performed in 1990 and 2000. This survey included questions regarding Balint groups, including their composition, management, and goals. RESULTS: More than half (54%) of respondent programs (n=159) have at least one Balint group, compared to 19% in 1990 and 60% in 2000. Of programs without Balint, 24% would like to have a Balint group, and 6% plan to initiate one within the following year. The proportion of groups meeting weekly decreased over time (80.9% in 1990 versus 40.4% in 2000 versus 11.7% in 2010). The proportion of peer only groups decreased (45.2% versus 53.6% versus 35.1%) while the proportion of groups with > 11 members increased (11.1% versus 15.8% versus 27.2%). Less than half of Balint group leaders reported going to formal training at the American Balint Society Leader's Intensive Workshop (41%). "Understanding the patient as a person" was seen as the main objective of Balint groups. CONCLUSIONS: Balint groups are still commonly occurring, but their implementation is changing. Groups are meeting less frequently and are more likely to be larger and heterogeneous. This trend and lack of formally trained/certified leaders may be decreasing the benefit to residents involved in Balint groups.

How we teach U.S. medical students to negotiate uncertainty in clinical care: a CERA study.

BACKGROUND AND OBJECTIVES: The patient relies on the physician to help negotiate medical evidence, particularly when experts disagree. For shared decision making to be most effective, the physician must disclose personal uncertainty. This study proposes to describe how uncertainty management is intentionally and systematically taught to medical students. METHODS: A cross-sectional survey was administered to all family medicine clerkship directors (FM CDs) at U.S. allopathic medical schools. Items evaluated the teaching of uncertainty in two domains (instruction and modeling). RESULTS: Eighty-six of 134 (64.18%) FM CDs surveyed completed the survey. Overall, an average of 2.6 hours was devoted to learning about clinical guidelines. The teaching objective addressed least by this sample was discussing uncertainty with the patient. Most curricula do not engage the medical students in how to discuss uncertainty with patients. Hypothesis testing revealed that the clerkship's general attitude toward the importance of teaching students how to deal with competing medical evidence is associated with both instruction and modeling behavior. DISCUSSION: FM CDs demonstrate a positive attitude toward teaching students how to deal with competing evidence. Clerkships do provide students with the opportunity to see faculty engage in uncertainty discussions with patients. Opportunities exist to improve medical student competence in discussing uncertainty in a productive manner. Clerkship directors influence curriculum development and implementation but through their attitude also construct a culture that can be positively aligned with teaching medical students how to negotiate uncertainty in clinical care.