The Cancer Pain Role Model Program of the Wisconsin Cancer Pain Initiative.

The Cancer Pain Role Model Program was established in 1990 by the Wisconsin Cancer Pain Initiative to train physicians to be role models for appropriate pain management. Community and academic physicians along with their "clinical partners," a nurse or pharmacist, were recruited to attend a 1-day education conference that included lectures, small group workshops, and development of an action plan. A total of 44 physicians and 55 clinical partners have attended two conferences (1990 and 1991). Participants listed 199 activities on their action plans; postconference surveys have documented initiation of 212 projects aimed at educating others, improving clinical care, resource development, educating self, or research. The Cancer Pain Role Model Program appears to be a promising means of transferring cancer pain information, legitimizing cancer pain as an important treatment issue, and institutionalizing cancer pain management.

Primary care physicians' experience with mental health consultation.

A total of 684 primary care physicians in Wisconsin participated in a survey designed to explore their experiences of consulting with and referring patients to mental health care professionals. The respondents indicated that they had only moderate access to mental health care professionals, and even less access when a patient was covered by Medicare or Medicaid or had no insurance. Physicians in group practices that included at least one mental health professional reported having better access to care than those in practices that did not include mental health services. Perceived access to mental health care services was not related to community size or to a managed care setting.

Does teaching by family physicians in the second year of medical school increase student selection of family practice residencies?

BACKGROUND AND OBJECTIVES: Most educators feel that early instruction by family physician teachers increases the probability of students selecting family practice residencies. METHODS: To examine this hypothesis, a retrospective cohort study was performed to evaluate residency selection of students who received their second-year Introduction to Clinical Medicine (ICM) teaching either from family physicians or other specialists (most commonly, internists). RESULTS: For the 971 students who could be followed to residency, 13.6% of those having family physicians as instructors and 15.7% of those having other specialists as instructors chose family practice residencies. The difference is not significant. CONCLUSION: It is probable that the effect of having a family physician as a second-year ICM instructor is not significant enough to be detected by a study of this size and is simply "washed out" by other factors. It is also possible that no positive effect of second-year teaching by family physicians on residency selection exists.

Factors associated with research interest and activity during family practice residency.

BACKGROUND: Family medicine lacks a tradition of research training during residency. Previous studies of research during residency have surveyed faculty to assess residents' research interests. In contrast, we directly assessed research interest and activity during residency by surveying all 203 Wisconsin family practice residents. METHODS: The survey instrument was a questionnaire that included questions about the appropriateness of research experience, interest in pursuing research during residency, involvement in research, and perceptions regarding program research support. The importance of factors that encourage research were evaluated. We then used stepwise discriminant analysis to assess whether residents with different levels of interest in research had different perceptions about program support and environmental factors that promote research. RESULTS: Of 143 respondents, most (85%) felt research experience was desirable, and 48% were interested in pursuing research during residency. Only 8% were active in research. Although faculty were perceived as having sufficient research skills and encouraging resident research, few residents responded that dedicated time, seminars on goals and methods of family practice research, or funding were available. Residents with research interests were more likely to respond that their faculty had sufficient research skills and knowledge. Active researchers rated time availability and access to resource personnel as highly important. Those interested, but not active, rated basic information, assistance in identifying topics, and a forum for presentation as highly important. CONCLUSION: Exposure to skilled and knowledgeable faculty researchers may stimulate interest in research. Teaching research goals and methods, assisting in identifying topics, and providing research forums, especially early in residency, may promote research activity. Dedicated time for research and availability of resource personnel will enhance this activity.

The Wisconsin Primary Care Organizations Consortium: a forum for the primary care medical specialties.

The Wisconsin Primary Care Organizations Consortium (WI-PCOC) is composed of the leadership of Wisconsin's primary care medical specialties whose four professional societies have a combined membership of about 3,900 physicians. Since 1992, WI-PCOC has explored the priorities and issues of importance of each organization, and has reviewed organizational resources to synchronize agendas and to avoid conflict. WIPCOC articulates policy supported by its member societies with a common voice; it does not set policy. WI-PCOC has worked with legislators, medical school deans, other specialty societies and other groups interested in primary care service and education. WI-PCOC member organizations aspire to work together to improve the level of health of Wisconsin citizens and their communities.

Physician attitudes toward research study participation: a focus group.

The Wisconsin Research Network (WReN) and the UW Health Education And Research Trial (HEART) sponsored a focus group to explore the attitudes of primary care physicians toward research in their practices. Physicians, representing a variety of practice groups, emphasized that research is a low priority in their organizations. All had participated in some form of research, are philosophically committed to research as important to primary care, but are hesitant to commit themselves to participation in further research. They emphasized that academic researchers need to understand the constraints of primary care practice, propose research ideas that are practical and interesting to care providers, provide relevant feedback to participating practices, and do the majority of the research work themselves so impositions on the practice are minimal. The traditional barriers to practice-based research, such as the cost of physician and staff time and diversion from other tasks, continue to be of concern when physicians consider participation in research projects.

A simple measurement of family care in medical practice.

This communication proposes a simple measure of the size of the family unit as perceived by the family physician. Use of the measure as an index for monitoring one's own practice is briefly discussed.

Using private practice settings for academically intensive family practice clerkships.

The Department of Family Medicine and Practice at the University of Wisconsin has designed and conducted an academically intensive third-year three-month family practice clerkship based in private practice settings. This experience differs from more traditional preceptorships in the amount of academic structure and quality control applied to the student's learning experience. This clerkship has demonstrated that extramural experiences can be as academically intensive and carefully monitored as traditional, referral-hospital-based clerkships in family practice or other basic medical disciplines. Increases in the level of continuity of care occur over the entire 12 weeks.

Diagnosed and possible undiagnosed asthma: a Wisconsin Research Network (WReN) Study. Wisconsin Research Network (WReN) Asthma Prevalence Study Group.

BACKGROUND: Adult-onset asthma is frequently encountered in primary care and is responsible for a large proportion of asthma morbidity and mortality. The primary goal of this survey was to describe the epidemiology of diagnosed and possible undiagnosed asthma in Wisconsin Research Network (WReN) practices. METHODS: Physicians from 59 practices interviewed a systematic sample of their clinical population, which included all patients encountered during office visits one day each week for 3 or 12 months, to obtain a history of physician-diagnosed asthma or symptoms suggesting undiagnosed asthma (wheezing and shortness of breath). Age at diagnosis or at onset of symptoms and current disease activity were also recorded. RESULTS: The 14,127 patients surveyed closely resembled the age-sex composition of the 1990 general and family practice component of the National Ambulatory Medical Care Survey. Physician-diagnosed asthma that was active within the previous year was reported by 6.1% of WReN patients (5.8% of patients younger than 20 years of age and 6.2% of adults). Undiagnosed asthma that was active within the previous year was reported by 3.3% (2.9% of patients younger than 20 years of age and 3.4% of adults). Adult-onset asthma was reported by 46.3% of all patients with diagnosed asthma; and 56.7% of patients with undiagnosed asthma reported that their symptoms began in adulthood. CONCLUSIONS: Adult-onset asthma accounts for approximately one half of all asthma cases. Since most patients with adult-onset asthma are managed by primary care physicians, practice-based research is necessary for the understanding, treatment, and possible prevention of this important disease.

Rate of case reporting, physician compliance, and practice volume in a practice-based research network study.

OBJECTIVE: Practice-based research is one method for answering questions about common problems that are seen infrequently in referral centers. We explored the potential limitations of this method. STUDY DESIGN: This was a prospective observational cohort study of participants in a practice-based research network who submitted data on 231 patients with dyspepsia from a total of 45,337 patient encounters over a 53-week period. Reporting of individual cases involved use of a relatively high-burden data instrument. Outcome measures were compared using rank correlation. POPULATION: We included 18 physicians in a Wisconsin research network study on initial management of dyspepsia in primary care settings. OUTCOMES MEASURED: The outcomes we measured were the rate of dyspepsia visits, average weekly patient volume, and self-reported compliance to the study protocol for each physician. RESULTS: A significant negative correlation existed between physician patient volume and the reported rate of dyspepsia visits. Self?reported compliance with the protocol was negatively correlated to patient volume and positively correlated to the reported rate of dyspepsia visits. CONCLUSIONS: Practice volume may influence the results in practice-based research. Investigators using practice-base research networks need to consider the complexity of their protocols and should be cognizant of compliance-sensitive measures.

Family practice research networks. Experiences from 3 countries.

Access to data about the clinical problems, patients, and processes that characterise family practice is essential for the development of this specialty. Practice-based research networks (PBRNs) play an increasing role in obtaining these data. We compared 3 PBRNs: one in Wisconsin in the United States, one in Wessex in the United Kingdom, and one in Nijmegen in the Netherlands. We organized our data into 4 key areas for review: the mission of the network, its contribution to the evidence base of family medicine, the management of the network, and the financing of the network infrastructure. Extending the evidence base of family practice is the overriding objective of these networks, and their main focus is on common morbidities. They provide access to unselected patient populations, but there are differences in their size. There are aspects of PBRNs that are common in countries with different health care systems, despite the fact that local circumstances--the research mission or the characteristics of the health care system under which they operate--determine their form and structure. Networks develop over time and their focus and activities may evolve. Financial support for these networks continues to be a problem.

The cost of primary care research.

A significant portion of research project costs is incurred before the receipt of grant funds. This poses a problem for the initiation of primary care research, especially in community practice settings. Potential investigators need financial support for staff time, training, pilot work, and grant proposal writing if primary care researchers are to compete successfully for grant funds. To find this support, we need to understand and eventually quantify the actual costs of research with attention to those that are incurred before the receipt of grant funds. We outline 10 phases of the research process and provide a model for understanding where costs are incurred and by whom. Costs include those associated with maintaining practice interest in research, supporting practice participation, and disseminating research findings. They may be incurred by either an academic center or a research network, by the practices and physicians themselves, or by an extramural funding source. The needed investment for initiating primary care research can be itemized and, with further research, quantified. This will enhance the arguments for capital investments in the primary care research enterprise.

Recruitment of private practices for primary care research: experience in a preventive services clinical trial.

BACKGROUND: Recruitment of community primary care practices for studies to improve health service delivery is important to many health care organizations. Prior studies have focused on individual physician recruitment or academic settings. METHODS: This descriptive study evaluated the efficiency and utility of three different recruitment methods to encourage community practice participation in a preventive services research trial. Primary care practices in four midwestern states were recruited using different sources for initial mailings (physician lists, practice lists, and a managed care organization's primary care network) and different recruiting methods. Outcome measures included response rates, participation rates, and comparative costs of each method. RESULTS: Of the 86 eligible practices contacted, 52 (60%) consented to participate. Mailing to individual physicians was the most cumbersome and expensive method and had the lowest response rate. Initial contacts with practice medical directors increased the participation rate substantially, and practice recruitment meetings improved both study participation and practice-project communication. CONCLUSIONS: Experience with these three methods suggests that the most efficient way to recruit practices for participation in a preventive services research trial involves targeted mailings and phone calls to medical directors, followed by on-site practice meetings.

Responses to questions frequently asked by medical students about family practice.

During their medical school years medical students are frequently exposed to misinformation about family practice from faculty members in other specialties. Responses to 26 questions frequently asked by medical students about family practice are presented with a review of recent literature. These responses may assist medical students and their advisors when considering careers in family practice.

Responses to questions by medical students about family practice.

Medical students frequently have questions about the specialty of family practice. Responses to 30 questions commonly asked about family practice are presented with a review of recent literature. These responses may assist medical students and their advisors in considering the choice of family practice as a career.

Ten central elements of family practice.

Previous studies of the content of family practice have analyzed the discipline in terms of the clinical problem content. Taking a different approach, a study group analyzed the care given to patients by family physicians irrespective of the specific clinical problems. Working with a reference group of family physicians in private practice, ten central elements were identified: (1) comprehensiveness of care, (2) anticipation of problems and continuity of care, (3) personal relationships with a patient, (4) medical knowledge and skills characteristic of family medicine, (5) values and attitudes that enhance family medicine, (6) problem definition and medical decision making, (7) problem management and resource coordination, (8) care of the individual within the family context, (9) involvement with the community, and (10) attentiveness to practice organization. This study provides a different point of departure for the design and evaluation of educational programs in family practice.