Exploring Family Medicine Residents' Experiences Teaching Medical Students.

INTRODUCTION: Near-peer teaching offered by residents is common in a medical students' educational career, so preparation of residents for their role as teachers is essential. Understanding resident perspectives on interactions with medical students may provide insight into this near-peer relationship and allow stakeholders to emphasize concepts that add value to this relationship when preparing residents to teach. This study presents the results from an inquiry focusing on a cohort of family medicine residents' experiences with medical students in their role as teachers. METHODS: Family medicine residents at a Southeastern US academic medical center participated in one of three focus groups to assess resident perceptions of their role in teaching students and approaches employed. We coded focus group transcripts for themes. RESULTS: Themes identified from questions on residents' perceptions of teaching role and employed teaching approaches focused on teaching interactions and methods. Six categories of major themes were derived from this qualitative analysis: (1) the learning environment, (2) stimulating learning, (3) supervising, (4) role modeling, (5) collaborating, and (6) transferring knowledge. Trends within these categories include creating a safe environment for clinical reasoning and inquiry, setting expectations, developing clinical reasoning skills through practical application of knowledge, providing appropriate student supervision and autonomy, and including students as part of the team. CONCLUSIONS: Residents adopted a variety of teaching approaches that assist medical students in their transition into and ability to function within a clinical environment. Findings from this study have implications for program directors and educators when preparing residents as teachers.

Patient-Centered Medical Home Status and Preparedness to Assess Resident Milestones: A CERA Study.

PURPOSE: The patient-centered medical home (PCMH) model has been proposed as the ideal model for delivering primary care and is focused on improving patient safety and quality, reducing costs, and enhancing patient satisfaction. The mandated Accreditation Council for Graduate Medical Education educational milestones for evaluation of resident competency represent the skills graduates will utilize after graduation. Many of these skills are reflected in the PCMH model. We sought to determine if residency programs whose main family medicine (FM) practice sites have achieved PCMH recognition are therefore more prepared to evaluate milestones. METHOD: A national Council of Academic Family Medicine Educational Research Alliance (CERA) survey of family medicine program directors (PDs) was conducted during June and July 2015 to determine if PCMH recognition influences PDs' ability to evaluate training methods and their level of preparedness to evaluate milestones. RESULTS: The response rate for the survey was 53.3% (252/473). Nearly two-thirds of the PDs (62.7%) reported that their main FM practice site had earned PCMH recognition. There was no statistical difference between non-PCMH-recognized vs PCMH-recognized programs in how PDs perceived that their program was prepared to assess residents' milestone levels overall (P=0.414). Residents of PCMH-recognized programs were more likely to receive training for team-based care (P=0.009), system improvement plans (P<0.001), root-cause analysis (P=0.002), and health behavior change (P=0.003). CONCLUSIONS: PCMH recognition itself did not improve preparedness of FM residency programs to assess milestones. Residents from programs whose main FM practice site is PCMH-recognized are more likely to be trained in the key concepts and tasks associated with the PCMH model, tools that they are expected to utilize extensively after graduation.

Setting Expectations About Feedback in Dental Education.

INTRODUCTION: Many dental students find the amount of direct feedback they receive in dental school to be both unfamiliar and uncomfortable, as many new hand-skill courses are added to familiar lecture courses and traditional paper-and-pencil tests. In turn, when students react poorly to routine professional feedback, dental school faculty often complain they are too fragile. To address this clear gap in expectations between students and faculty in regard to feedback activities, this half-day workshop was developed for use during student orientation. METHODS: In this workshop, students learn the theory of deliberate practice and the role that professional feedback will play in their training. Small-group workshops discuss past student experiences with feedback and use an origami exercise to explore student reactions to feedback. As is commonly done in technique courses, discussions about self- and peer assessment raise students' comfort levels with respect to sharing their work with their peers. Additionally, addressing feedback issues early in their professional education makes students aware of feedback's necessity in their professional development and helps them to deal with the emotional impact. RESULTS: When we evaluated this course in 2014 and 2015, students rated this activity significantly higher than other orientation activities. DISCUSSION: After several years of working with students who have had this orientation, faculty and administrators consider it highly valuable for setting expectations about feedback. They have also experienced fewer student concerns and complaints regarding feedback issues.

Introversion and medical student education: challenges for both students and educators.

ISSUE: Introversion is one of the personality factors that has been shown to be associated with performance in medical school. Prior cross-sectional studies highlight performance evaluation differences between introverted and extraverted medical students, though the mechanisms and implications of these differences remain relatively unexplained and understudied. This gap in the literature has become more salient as medical schools are employing more interactive learning strategies into their curricula which may disproportionately challenge introverted learners. EVIDENCE: In this article, we provide an overview and working definition of introversion as a valid construct occurring on a continuum. We apply a goodness of fit model to explore how various medical training contexts may be more or less challenging for introverted students and the potential consequences of a poor fit. As preliminary support for these hypothesized challenges, we share observations from students self-identified as introverts. Examples include introverted students feeling at times like misfits, questioning a need to change their identity to succeed in medical school, and being judged as underperformers. We offer pragmatic suggestions for improving the fit between introverted students and their training contexts, such as teachers and students pausing between a question being asked and the initial response being offered and teachers differentiating between anxious and introverted behaviors. We conclude with suggested areas for future qualitative and quantitative research to examine how medical school curricula and the teaching environment may be differentially impacting the learning and health of introverted and extraverted students. IMPLICATIONS: Extraverted behaviors will continue to be an important part of medical training and practice, but the merits of introverted behaviors warrant further consideration as both medical training and practice evolve. Educators who make manageable adjustments to current teaching practices can improve the learning for both introverted and extraverted styles of academic engagement.

Colorectal cancer risk information presented by a nonphysician assistant does not increase screening rates.

OBJECTIVE: To determine the effectiveness of presenting individualized colorectal cancer (CRC) risk information for increasing CRC screening rates in primary care patients at above-average risk of CRC. DESIGN: Randomized controlled trial. SETTING: Georgia Regents University in Augusta-an academic family medicine clinic in the southeastern United States. PARTICIPANTS: Outpatients (50 to 70 years of age) scheduled for routine visits in the family medicine clinic who were determined to be at above-average risk of CRC. INTERVENTIONS: Individualized CRC risk information calculated from the Your Disease Risk tool compared with a standard CRC screening handout. MAIN OUTCOME MEASURES: Intention to complete CRC screening. Secondary measures included the proportions of subjects completing fecal occult blood tests, flexible sigmoidoscopy, and colonoscopy. RESULTS: A total of 1147 consecutive records were reviewed to determine eligibility. Overall, 210 (37.7%) of 557 eligible participants were randomized to receive either individualized CRC risk information (prepared by a research assistant) or a standard CRC screening handout. The intervention group had a mean (SD) age of 55.7 (4.8) years and the control group had a mean (SD) age of 55.6 (4.6) years. Two-thirds of the participants in each group were female. The intervention group and the control group were matched by race (P = .40). There was no significant difference between groups for intention to complete CRC screening (P = .58). Overall, 26.7% of the intervention participants and 27.7% of the control participants completed 1 or more CRC screening tests (P = .66). CONCLUSION: Presentation of individualized CRC risk information by a nonphysician assistant as a decision aid did not result in higher CRC screening rates in primary care patients compared with presentation of general CRC screening information. Future research is needed to determine if physician presentation of CRC risk information would result in increased screening rates compared with research assistant presentation.

Measuring psychological flexibility in medical students and residents: a psychometric analysis.

PURPOSE: Psychological flexibility involves mindful awareness of our thoughts and feelings without allowing them to prohibit acting consistently with our values and may have important implications for patient-centered clinical care. Although psychological flexibility appears quite relevant to the training and development of health care providers, prior research has not evaluated measures of psychological flexibility in medical learners. Therefore, we investigated the validity of our learners' responses to three measures related to psychological flexibility. METHODS: Fourth-year medical students and residents (n=275) completed three measures of overlapping aspects of psychological flexibility: (1) Acceptance and Action Questionnaire-II (AAQ-II); (2) Cognitive Fusion Questionnaire (CFQ); and (3) Mindful Attention and Awareness Questionnaire (MAAS). We evaluated five aspects of construct validity: content, response process, internal structure, relationship with other variables, and consequences. RESULTS: We found good internal consistency for responses on the AAQ (α=0.93), MAAS (α=0.92), and CFQ (α=0.95). Factor analyses demonstrated a reasonable fit to previously published factor structures. As expected, scores on all three measures were moderately correlated with one another and with a measure of life satisfaction (p<0.01). CONCLUSION: Our findings provide preliminary evidence supporting validity of the psychological flexibility construct in a medical education sample. As psychological flexibility is a central concept underlying self-awareness, this work may have important implications for clinical training and practice.

Racial disparities and barriers to colorectal cancer screening in rural areas.

INTRODUCTION: This study examined barriers to colorectal cancer (CRC) screening in people living in rural areas. METHODS: We identified 2 rural counties with high rates of CRC and randomly contacted county residents by telephone using a published listing. RESULTS: Six hundred thirty-five of the 1839 eligible respondents (34.5%) between the ages of 50 and 79 years living in McDuffie and Screven counties, Georgia, agreed to complete the survey. The mean age was 62.2 years (SD, ±7.5 years); 72.4% were women, 79.4% were white, and 19.5% were African American. African-American respondents had lower CRC screening rates (50.4%) than whites (63.4%; P = .009). Significantly more African Americans compared with whites reported barriers to CRC screening. Based on logistic regression analyses, having a physician recommend CRC screening had the strongest association with having a current CRC screening, regardless of race. CONCLUSIONS: Important racial differences existed between African Americans and whites regarding the barriers to CRC screening and factors impacting current screening. However, endorsement of a small set of questionnaire items--not race--had the strongest association with being current with screening. Physician recommendation for CRC screening had the strongest association with being current with CRC screening.

Teaching medical error apologies: development of a multi-component intervention.

BACKGROUND AND OBJECTIVES: Apologizing is an important component in addressing medical errors; yet, offering apologies continues to challenge physicians. To address limitations of prior educational interventions, a multi-faceted, apologies intervention was developed to provide medical students with increasingly applied learning opportunities. METHODS: First-year medical students taking a professionalism course at the authors' Southeastern medical school in 2008 or 2009 were eligible for the study. Data from their assigned activities and a post-intervention survey were analyzed. RESULTS: A total of 384 students contributed study data; 57.8% were male, 58.6% white, 10.9% Asian-Indian, 10.9% Asian-Other, and 7.6% African-American. Seventy-four percent of students considered tasks as useful or extremely useful. Student confidence in providing effective apologies increased as well as their comfort in disclosing errors to a faculty member or patient. Perceived importance of apology skills similarly increased. Apologies written by female authors were rated higher in effectiveness by peers than apologies written by male authors. Apology evaluators adopting patient perspective were more critical than evaluators adopting peer perspective. No race differences were found. CONCLUSIONS: This intervention was perceived useful by students and demonstrated medium to large effect size changes in importance, confidence, and comfort around apology errors. The higher evaluations of apologies written by female authors as well as the lower evaluations by evaluators adopting patient perspective warrant further consideration. Additional research is also warranted on streamlining and implementing the intervention for other institutions and ultimately how actual student apology behaviors are later affected.

Nasolaryngoscopy in a family medicine clinic: indications, findings, and economics.

BACKGROUND: Nasopharyngeal complaints are common among patients who present to primary care. Patients with these complaints are often referred for nasolaryngoscopy evaluation to exclude serious conditions such as laryngeal cancer. METHODS: This study is a retrospective case series in which 276 charts of adult outpatients who were referred for nasolaryngoscopy were reviewed. We examined patient demographics, procedure indications and findings, complications, and changes in clinical management. RESULTS: Nasolaryngoscopy was completed in 273 (98.9%) patients (mean age, 51.3 +/- 14.6 years; 71.4% were women). The most common indications for nasolaryngoscopy were hoarseness (51.3%), globus sensation (32.0%), and chronic cough (17.1%); the most common findings included laryngopharyngeal reflux (42.5%), chronic rhinitis (32.2%), and vocal cord lesions (13.2%). Three patients (1.1%) were diagnosed with laryngeal cancer and this diagnosis was significantly associated with a history of smoking (P = .03). No major complications occurred. CONCLUSIONS: We found that nasolaryngoscopy was a safe procedure in the primary care setting, and no major complications occurred in our series. Patients who have ever smoked and complain of hoarseness are at higher risk for laryngeal cancer. An alarming 1% of patients in our series were diagnosed with laryngeal cancer. This is the first study to define the rates of laryngopharyngeal reflux, vocal cord lesions, and laryngeal cancer among primary care patients.

Why a medical career and what makes a good doctor? Beliefs of incoming United States medical students.

INTRODUCTION: Beginning medical students' beliefs about the medical profession have been well studied internationally but have only been minimally studied in the United States (U.S.) recently. Up-to-date research on U.S. medical students' beliefs is warranted so educators can employ these predispositions as a baseline for curriculum and student professional development. METHODS: We conducted focus groups with a first-year class (n=189) of U.S. medical students at the beginning of their academic year. In an iterative theming process, investigators worked in dyads and subsequently as a group to develop a list of preliminary themes expressed in the focus groups. Investigators individually sorted preliminary themes into similar categories. All sorted preliminary themes and categories were placed in a matrix from which final themes were derived. FINDINGS: Investigators found eight themes for the question "Why pursue a career in medicine?" and six themes for "What makes a good doctor?". Students expected medicine to be intellectually and personally fulfilling, they expected to be respected by the community, indicated that early experiences with medicine impacted their career choices, and anticipated that a medical career would yield financial security. A good doctor was described as a committed, smart, decisive leader who enthusiastically partners with patients via effective interpersonal skills. DISCUSSION: Beginning U.S. medical students hold multi-faceted beliefs about medicine that are similar to international medical students' beliefs. Themes related to patient-centeredness, decisive leadership, and intellectual curiosity have particular utility in curriculum and professional development and should not be ignored. Administrators seeking to expand the physician workforce should consider early experiences, status, and monetary rewards.

The prevalence of dysphagia in primary care patients: a HamesNet Research Network study.

PURPOSE: A number of disorders cause dysphagia, which is the perception of an obstruction during swallowing. The purpose of this study was to determine the prevalence of dysphagia in primary care patients. METHODS: Adults 18 years old and older were the subjects of an anonymous survey that was collected in the clinic waiting room before patients were seen by a physician. Twelve family medicine offices in HamesNet, a research network in Georgia, participated. RESULTS: Of the 947 study participants, 214 (22.6%) reported dysphagia occurring several times per month or more frequently. Those reporting dysphagia were more likely to be women (80.8% women vs 19.2% men, P = .002) and older (mean age of 48.1 in patients with dysphagia vs mean age of 45.7 in patients without dysphagia, P = .001). Sixty-four percent of patients with dysphagia indicated that they were concerned about their symptoms, but 46.3% had not spoken with their doctor about their symptoms. Logistic regression analyses showed that increased frequency [odds ratio (OR) = 2.15, 95% CI 1.41-3.30], duration (OR = 1.91, CI 1.24-2.94), and concern (OR = 2.64, CI 1.36-5.12) of swallowing problems as well as increased problems eating out (OR = 1.72, CI 1.19-2.49) were associated with increased odds of having talked to a physician. CONCLUSIONS: This is the first report of the prevalence of dysphagia in an unselected adult primary care population. Dysphagia occurs commonly in primary care patients but often is not discussed with a physician.

The current state of flexible sigmoidoscopy training in family medicine residency programs.

BACKGROUND AND OBJECTIVES: The US Preventive Services Task Force has recommended that adults ages 50 and over be screened for colorectal cancer. Flexible sigmoidoscopy (FS) is one available screening option. This study determined the current state of FS training in US family medicine residencies. METHODS: Directors of the Accreditation Council for Graduate Medical Education-accredited family medicine residencies were surveyed regarding FS training. RESULTS: Of 486 mailed surveys, 370 (76%) were completed and returned. Fifty-two percent of responding residency programs trained at least one resident in FS in 2003. Residents in these programs performed a mean of 20.1 +/- 1.2 FSs during their training. In 2003, 44% of family medicine graduates from these programs were certified by their programs as competent to perform FS. Fewer residents were certified in FS by programs in the eastern versus western United States. Military programs certified more residents than did nonmilitary programs. CONCLUSIONS: More than half of programs offered FS training, but less than half of family medicine graduates were certified by their programs as competent. There were significant differences for FS training by region and program type.

Evaluating perceptions of community-based physicians from a high-retention clerkship.

OBJECTIVE: This study's objective was to ascertain factors contributing to high retention of community-based sites and their physicians in a 3-decade-old family medicine clerkship. METHODS: Focus groups were conducted with community-based physicians from the Medical College of Georgia's family medicine clerkship. Transcripts were analyzed using an iterative process regarding physicians' initial and ongoing motivations for participating in the clerkship. RESULTS: Thirteen physicians participated. Six themes were generated: family medicine promotion, valued role of teaching, leadership style, clerkship ownership, resources, and challenges. CONCLUSIONS: In addition to intrinsic motivators such as valuing the role of teaching the next generation of physicians and promoting the family medicine specialty, the participative leadership style of a clerkship may be an important factor in physicians' decision to teach in a clerkship. The physicians in this study described having collegial working relationships with the clerkship leaders and receiving consistent support in implementing objectives. Physicians attributed their high level of involvement and investment as a product of being respected partners in defining the clerkship. Financial support and teaching resources were also considered salient. A follow-up study with a larger population is warranted to support the importance of leadership style and other external motivating factors toward a clerkship's physician retention.

Office-based unsedated ultrathin esophagoscopy in a primary care setting.

PURPOSE: Gastroesophageal reflux disease is common and with time may be complicated by Barrett's esophagus and esophageal adenocarcinoma. Upper gastrointestinal endoscopy, including esophagoscopy, is the procedure of choice to diagnose Barrett's esophagus and other esophageal disease. The use of unsedated ultrathin esophagoscopy (UUE) has been reported by gastroenterologists in specialized endoscopy units and otolaryngologists in outpatient otolaryngology offices, but UUE has not been previously described in a primary care setting. This study examines the feasibility of office-based UUE in primary care. METHODS: This study is a retrospective chart review in a university-based family medicine clinic in the southeastern United States. Charts were reviewed of 56 adult outpatients who were referred for further evaluation of reflux symptoms that persisted after at least 4 weeks of therapy with histamine(2) receptor agonists or proton pump inhibitors and who elected to undergo UUE in the primary care setting. Patient demographics, procedure indications and findings, changes in clinical management, and procedure times were recorded. RESULTS: One hundred percent of patients asked to participate in UUE were willing to undergo the procedure (mean age 48.3 +/- 1.6 y, 57.1% women); 95% of the patients tolerated UUE. Barrett's esophagus was diagnosed in 5.7% (n = 3) of the patients. Mean procedure time was 5.5 +/- 1.7 min. No complications were reported in this series. CONCLUSIONS: Initial data suggest that UUE is feasible in primary care, with the majority of patients tolerating the procedure. UUE may be an efficient method of examining the distal esophagus.

EMBASE versus MEDLINE for family medicine searches: can MEDLINE searches find the forest or a tree?

OBJECTIVE: Many physicians access electronic databases to obtain up-to-date and reliable medical information. In North America, physicians typically use MEDLINE as their sole electronic database whereas in Europe, physicians typically use EMBASE. While MEDLINE and EMBASE are similar, their coverage of the published literature differs. Searching a single literature database (eg, MEDLINE or EMBASE) has been shown not to yield all available citations, and using two or more databases yields a greater percentage of these available citations. This difference has been demonstrated in a variety of disciplines and in family medicine using the term "family medicine," but differences have not been shown using specific diagnostic terms common in family medicine. We sought to determine whether searching EMBASE with terms for common family medicine diagnoses yields additional references beyond those found by using MEDLINE alone. DESIGN: Literature search comparison. SETTING: An academic medical centre in the United States. INTERVENTIONS: Fifteen family medicine topics were selected based on common diagnoses in US primary care health visits as described in a National Health Care Survey on Ambulatory Care Visits. To promote relevance to family medicine physicians and researchers, the qualifiers "family medicine" and "therapy/therapeutics" were added. These topics were searched in EMBASE and MEDLINE. Searches were executed using Ovid search engine and were limited to the years 1992 to 2003, the English language, and human subjects. Total, duplicated, and unique (ie, nonduplicated) citations were recorded for each search in each database. MAIN OUTCOME MEASURES: Number of citations for the 15 topics. RESULTS: EMBASE yielded 2246 (65%) of 3445 total citations, whereas MEDLINE yielded 1199 citations. Of the total citations, only 177 articles were cited in both databases. EMBASE had 2092 unique citations to MEDLINE's 999 unique citations. EMBASE consistently found more unique citations in 14 of the 15 searches (P = .0005). CONCLUSION: Overall, EMBASE provides twice as many citations per search as MEDLINE and provides greater coverage of total retrieved citations. More citations do not necessarily mean higher-quality citations. In a comprehensive search specific to family medicine, combined EMBASE and MEDLINE searches could yield more articles than MEDLINE could alone.

Office-based ultrathin esophagogastroduodenoscopy in a primary care setting.

BACKGROUND: Upper gastrointestinal complaints are common in primary care. These patients are often referred for evaluation with the use of esophagogastroduodenoscopy. This study examines the feasibility and safety of office-based ultrathin (diameter, 5.9 mm) esophagogastroduodenoscopy (u-EGD) without conscious sedation in a primary care setting. METHODS: This study is a retrospective chart review in a university-based family medicine residency in the southeastern United States. Charts were reviewed for adult outpatients (N = 126) who were referred for further evaluation of heartburn, dyspepsia, or epigastric pain and who elected to undergo u-EGD procedure. We examined the number of patients willing to undergo office-based u-EGD, patient demographics, procedure indications and findings, patient request for oral benzodiazepines, and procedure and recovery times. RESULTS: Of the 132 patients asked to participate in office-based u-EGD, 126 (95.4%) were willing to undergo this procedure (mean age, 47.6 +/- 1.3; 75% women). Of 126 patients, 122 (96.8%) tolerated office-based u-EGD, and 80.6% of patients requested oral anxiolytic medications. Significantly more women than men requested oral anxiolytic medications (84.0% versus 65.6%, respectively; P = .026). The retroflexion maneuver was completed in 120 of 122 (98.4%) patients, and the second portion of duodenum was reached in 122 of 122 (100%) patients. Mean procedure time was 16.9 +/- 0.7 minutes, and mean recovery time was 3.8 +/- 0.2 minutes. There were no complications reported in this case series. CONCLUSIONS: The majority of patients can tolerate office-based u-EGD without conscious sedation in a primary care setting, but most patients request oral anxiolytic medications. Statistically more women request oral anxiolytic medications than do men.