Outpatient precepting of international medical graduates in family medicine.

BACKGROUND: The purpose of this study was to examine outpatient precepting for international medical graduates (IMGs) in family medicine residencies. The education of IMGs in residency programs has been a subject of concern. Multiple obstacles in acculturation may negatively influence IMGs' thoughts/feelings and subsequently affect their learning in teacher-learner interaction especially during a time-constrained environment like outpatient precepting. However, there is no research on IMGs' thoughts and feelings during outpatient precepting. METHODS: We used qualitative research using multiple methods, primarily semi-structured individual interview during Interpersonal Process Recall (IPR). We purposefully sampled IMGs from three family medicine residency programs and videotaped their outpatient precepting. As a standard for comparison, we also videotaped US medical graduates (USMGs). We used multiple methods to explore their thoughts/feelings during precepting: brief interview, preceptor questionnaire, video review, and IPR debriefing of the precepting encounter. For analysis, we developed thematic codes from IPR transcripts and explored their consistency with data from the three other sources. RESULTS: Seven themes emerged: cultural differences, language barriers, clinical performance, relationship, preceptor's teaching behaviors/attitudes, internalized process, and external factors. IMGs experienced various negative thoughts and feelings related to language barriers and cultural differences. These internalized processes adversely influenced their learning attitudes, precepting behaviors, and clinical performance. CONCLUSIONS: Precepting is more stressful for IMGs than for USMGs. IMGs need more specific orientation for outpatient precepting, and preceptors need further opportunity to reflect on their precepting skills for IMGs. Residency programs may do well to develop and test a curriculum and learning environment to meet IMGs' special needs.

Pharmacist integration into the medical home: qualitative analysis.

OBJECTIVE: To determine the acceptance and attitudes of family medicine physicians, clinical and nonclinical office staff, pharmacists, and patients during pharmacist integration into a medical home. DESIGN: Qualitative study. SETTING: Pittsburgh, PA, area from August 2009 to June 2010. PARTICIPANTS: Physicians, staff, pharmacists, and patients at four single-specialty family medicine office practices functioning as medical homes. MAIN OUTCOME MEASURES: Attitudes, acceptance, barriers, and problems identified by participants. RESULTS: A total of 84 interviews were conducted: 21 interviews with family medicine physicians, 26 with patient care staff, 9 with nonclinical staff, 13 with patients, 6 with pharmacists, and 8 with office managers. Five main themes emerged from each group regarding the integration of a pharmacist, including positive overall feeling; clinical, educational, and time-saving benefits to the various groups; challenges understanding the role of the pharmacist; improved workflow and integration resulting from pharmacist flexibility and motivation; and suggestions to increase the pharmacists' time in each office. Pharmacists felt that they were accepted within 6 months of the integration process and that time management was a challenge. CONCLUSION: Participants felt that inclusion of a pharmacist into their practice improves the quality of patient care, provides a valuable resource for all providers and staff, and empowers patients. The initial concerns of the clinical and nonclinical staff disappeared within the first months of pharmacist integration. These results provide guidance to clinicians and insight into strategies for building a pharmacist-integrated medical home team.

A view from retirement.

Five years after retiring from family practice, I still miss my patients.

Do probiotics reduce adult lactose intolerance? A systematic review.

PURPOSE: To assess the efficacy of oral probiotics in adults with lactose intolerance through a systematic review of its effects on symptoms and breath hydrogen tests, and whether adding probiotics to nonfermented dairy products decreases lactose intolerance at that meal. METHODS: We searched randomized controlled trials published between 1966 and December 2002. Databases in the search strategy included Medline and AMED. We reviewed references of clinical trials and contacted authors of major articles and manufacturers of probiotic commercial products. Quality assessment was based on the McMaster guides and was performed by 5 independent reviewers. Data extraction was performed by 2 reviewers. RESULTS: A master list of 90 articles was compiled. Ten articles met inclusion and exclusion criteria and were consistent with our clinical question. Of the 9 studies that measured breath hydrogen, 3 were positive, 3 were negative, and 3 had both positive and negative results. Of the 7 studies that measured symptoms, 1 yielded positive results, 5 were negative, and 1 had both positive and negative outcomes. CONCLUSIONS: Probiotic supplementation in general did not alleviate the symptoms and signs of lactose intolerance in adults in this review. Some evidence suggests that specific strains, concentrations, and preparations are effective. Further clinical trials of specific strains and concentrations are necessary to delineate this potential therapeutic relationship.

Orienting interns to being second-year residents.

BACKGROUND: Although orientation to the first year of residency is universal in family practice residencies, there is no published information on preparing first-year residents to become upper-level residents, an almost equally dramatic change. METHODS: We conducted a national survey of all 484 family practice residency directors by e-mail and regular mail. RESULTS: The total response was 365 (75.4%). Slightly more than half (185) of the residencies had a formal program to prepare for the transition to second-year resident. Both faculty, and upper-level residents taught or exchanged information using multiple methods of teaching but mostly lectures and seminars. Topics included practical issues related particularly to new responsibilities, teaching and supervising skills, and the general topics of leadership and communication. An important minority objected to these orientations, expressing concern that they distracted from the ultimate goal of training competent practitioners. CONCLUSIONS: Orientation to the second year of residency is common, brief, and specific. No evaluation of the value of these programs exists.