Understanding the exercise habits of residents and attending physicians: a mixed methodology study.

BACKGROUND AND OBJECTIVES: Although the benefits of exercise are well known, rates of exercise among residents are much lower than those of attendings or medical students. Little is known about the barriers that prevent residents from exercising regularly. This mixed methodology study identifies and compares these barriers for resident and attending physicians practicing in the same setting. METHODS: We conducted three focus groups with first-year and senior residents and attending physicians in the University of Missouri Department of Family and Community Medicine from April to August 2013. We also administered a survey inquiring about exercise rates and habits to 110 resident and attending physicians in the same department using both paper and electronic versions. RESULTS: During both inpatient and non-inpatient rotations, residents reported exercising less than attending physicians. No residents exercised more than 150 minutes/week during inpatient rotations compared to 18.42% of attendings. Only 6.9% of residents exercised more than 150 minutes/week during non-inpatient rotations, compared to 25% of attendings. Residents and attendings reported different barriers to regular exercise. Residents reported lack of time for a traditional structured workout as a major barrier, which leads to an adversarial relationship between work and exercise. CONCLUSIONS: Residency programs can help residents overcome exercise barriers by reframing exercise expectations to include more frequent but brief periods of exercise during the workday and by developing a supportive exercise culture. Changing worksite environments to support physician exercise may improve physician wellness.

Resident duty hour changes: impact in the patient-centered medical home.

BACKGROUND AND OBJECTIVES: Family medicine residency programs are challenged with balancing hospital-based training with a longitudinal primary care continuity experience. In response to the Preparing the Personal Physician for Practice (P4) Initiative, the University of Missouri (MU) Family Medicine Residency Program sought to increase the presence of its residents in their continuity clinic, ie, the patient-centered medical home (PCMH). While initially successful, these efforts encountered formidable barriers with the July 2011 duty hour regulations from the Accreditation Council for Graduate Medical Education (ACGME). METHODS: PCMH hours and visit numbers were collected and analyzed for MU residents from July 2005 through June 2012. RESULTS: Comparing the 2 years before the P4 schedule changes to the first 3 years after the P4 changes, MU first-year residents experienced a 27% increase in patient visits with a 13% increase in hours. In the subsequent 2 years, which incorporated compliance with the new ACGME regulations, first-year residents experienced a 33% decrease in visits with a 25% decrease in hours. This negated the increases seen with the previous P4 schedule changes, and residents in all years of training experienced less visits, less hours, and less visits per hour. CONCLUSIONS: New duty hour regulations not only limit the time resident physicians spend in the hospital but also their experience in the ambulatory setting. Considering the emphasis family medicine training programs place on continuity of care and the PCMH, the new regulations will have significant implications for these programs.

The family medicine chief resident: a national survey of leadership development.

BACKGROUND AND OBJECTIVES: The chief resident position is a potential incubator for future leaders in family medicine. This national survey of family medicine residency programs shows that 97% of programs have a chief resident, and 84% of these are in their third year of training. However, the responsibilities, preparation, and selection for this role vary widely. At the University of Missouri (MU), we developed a unique leadership curriculum to enhance training for this role that includes attendance at leadership conferences, acquisition of specific skills such as time management and communication, defined responsibilities, and administrative time to complete duties. A survey of former MU chief residents found that aspects of the position such as leadership training and increased exposure to faculty were most valued while schedule tasks were seen as least desirable. Former chief residents were more likely to teach medical students or residents in their current practice compared to those who had not been a chief resident.

Treatment of knee osteoarthritis.

Knee osteoarthritis is a common disabling condition that affects more than one-third of persons older than 65 years. Exercise, weight loss, physical therapy, intra-articular corticosteroid injections, and the use of nonsteroidal anti-inflammatory drugs and braces or heel wedges decrease pain and improve function. Acetaminophen, glucosamine, ginger, S-adenosylmethionine (SAM-e), capsaicin cream, topical nonsteroidal anti-inflammatory drugs, acupuncture, and tai chi may offer some benefit. Tramadol has a poor trade-off between risks and benefits and is not routinely recommended. Opioids are being used more often in patients with moderate to severe pain or diminished quality of life, but patients receiving these drugs must be carefully selected and monitored because of the inherent adverse effects. Intra-articular corticosteroid injections are effective, but evidence for injection of hyaluronic acid is mixed. Arthroscopic surgery has been shown to have no benefit in knee osteoarthritis. Total joint arthroplasty of the knee should be considered when conservative symptomatic management is ineffective.

The University of Missouri integrated residency: evaluating a 4-year curriculum.

BACKGROUND AND OBJECTIVES: Several approaches to merging residency training and medical school education have been attempted over the past 20 years. This study describes and evaluates an integrated family medicine residency programa 4-year program that overlaps with the final year of medical school. METHODS: We retrospectively analyzed multiple data sources, including In-Training Examination scores, patient visit profiles, resident demographics, and graduate surveys. RESULTS: Integrated residents (IRs) perform significantly better than traditional residents on In-Training Examinations at each year of residency training, with the difference in mean scores decreasing over time (67.8, 39.6, and 33.0 points better in the first, second, and third residency years). No evidence of increased patient continuity or panel size was noted. A higher proportion of IRs serve as chief residents, rate their residency experience as "excellent," and remain with the program through graduation. Practice characteristics immediately after residency do not significantly differ. Financial benefits are evident for the IRs as well as the hosting department. CONCLUSIONS: This integrated program offers several benefits for both the medical student and the residency program, and it is a potential model for academic residencies aiming to recruit and retain a higher percentage of their own schools' students.

Testicular torsion.

Each year, testicular torsion affects one in 4,000 males younger than 25 years. Early diagnosis and definitive management are the keys to avoid testicular loss. All prepubertal and young adult males with acute scrotal pain should be considered to have testicular torsion until proven otherwise. The finding of an ipsilateral absent cremasteric reflex is the most accurate sign of testicular torsion. Torsion of the appendix testis is more common in children than testicular torsion and may be diagnosed by the "blue dot sign" (i.e., tender nodule with blue discoloration on the upper pole of the testis). Epididymitis/orchitis is much less common in the prepubertal male, and the diagnosis should be made with caution in this age group. Doppler ultrasonography may be needed for definitive diagnosis; radionuclide scintigraphy is an alternative that may be more accurate but should be ordered only if it can be performed without delay. Diagnosis of testicular torsion is based on the finding of decreased or absent blood flow on the ipsilateral side. Treatment involves rapid restoration of blood flow to the affected testis. The optimal time frame is less than six hours after the onset of symptoms. Manual detorsion by external rotation of the testis can be successful, but restoration of blood flow must be confirmed following the maneuver. Surgical exploration provides definitive treatment for the affected testis by orchiopexy and allows for prophylactic orchiopexy of the contralateral testis. Surgical treatment of torsion of the appendix testis is not mandatory but hastens recovery.

Changing practice patterns of family medicine graduates: a comparison of alumni surveys from 1998 to 2004.

BACKGROUND AND OBJECTIVE: The University of Missouri family medicine residency has 297 family physician graduates. We suspected that the practice patterns of graduates were changing. METHODS: All graduates of the residency were surveyed in 1998, 2001, and 2004, asking about practice patterns. To characterize current practice characteristics and scope, we used the latest survey returned by each respondent. We analyzed data for persons who returned all 3 surveys to examine trends across surveys. RESULTS: Annual response rates ranged from 58% to 78%. Of graduates who responded to all 3 surveys, fewer graduates care for patients in the hospital (71.3%, 1998; 56.5%, 2004), practice obstetrics (40.7%, 1998; 23.2%, 2004), or provide primary care for their patients in the emergency department (25.9%, 1998; 13.0%, 2004). Fewer recent graduates perform flexible sigmoidoscopy or exercise electrocardiograms. Graduates who are practicing obstetrics are more likely to be rural or to have graduated since 1994. Those performing flexible sigmoidoscopy are more likely to be male or to have graduated before 1994. The perceived need for more training in practice management is higher for more recent graduates (14.9% for 1975 to 1983 graduates; 31.9% for 1994 to 2003 graduates). CONCLUSIONS: Across the 3 surveys, there was a decline in the proportion of graduates of this family medicine residency program performing procedures, obstetrics, intensive care unit care, or hospital medicine. This study highlights how the practices of family medicine residency graduates may change over time. Data regarding residency graduate practice profiles may help predict the knowledge and skills residency graduates will need in their future practices and evaluate the impact of the Future of Family Medicine recommendations.

Recurrent vulvovaginal candidiasis.

Recurrent vulvovaginal candidiasis affects five percent of women of child-bearing age. The most common organism is Candidia albicans, but an increasing number of infections are caused by nonalbicans species. Fungal culture directs treatment as nonalbicans species may be azole resistant. C. albicans will respond to anyazole antifungal. Treat C. glabrata with boric acid. Maintenance therapy should be started immediately after treatment of the acute episode and should last for six months.

The ACGME core competencies: a national survey of family medicine program directors.

BACKGROUND AND OBJECTIVES: Beginning in July 2002, all residencies were required to show that their residents were obtaining competency in six core areas defined by the Accreditation Council for Graduate Medical Education (ACGME). METHODS: In 2003, we surveyed all 444 family medicine program directors regarding the ACGME Core Competencies and how programs evaluated them. RESULTS: A total of 287/444 (64.6%) responded. Almost all (279/287) had heard of the ACGME Core Competencies, and most (257/287) had begun to implement evaluation programs. Of program directors responding, 67.6% identified patient care as the most important competency. Evaluation methods most frequently used were active precepting (76.0%), record review (72.8%), and procedure logs (63.8%). The least commonly used tools were OSCE (9.1%), audit of computer utilization and knowledge (10.5%), and simulations (11.1%). Respondents identified time (74.3 %) and faculty development (13.0%) as primary implementation barriers. CONCLUSIONS: Program directors believe that patient care is the most important competency. Some programs are not yet attempting to address the competencies, and some were unaware of the accreditation implications of noncompliance with the Outcome Project. Time was identified as the major barrier to implementing core competency evaluation methods.

Testicular microlithiasis and its relation to testicular cancer on ultrasound findings of symptomatic men.

PURPOSE: We reviewed testicular microlithiasis (TM) on scrotal ultrasound in relation to the incidence of testicular neoplasm in males 17 to 45 years old with scrotal symptoms. MATERIALS AND METHODS: We reviewed the radiographic and medical records of males age 4 weeks to 84 years with symptomatic complaint of scrotal pain or swelling between September 1998 and April 2002. Subgroup analysis was performed on 160 male patients between 17 and 45 years old since they were at higher risk for testicular carcinoma. RESULTS: TM was found in 12 patients (8%) and concomitant testicular neoplasm was found in 4 (33%) symptomatic individuals age 17 to 45. In the 148 (93%) patients without testicular microlithiasis, concomitant testicular neoplasm was found in 2 individuals (2%). Statistical analysis revealed a relative risk of testicular neoplasm in the presence of TM to be 36.5 (CI 4.2-429.6) in our symptomatic population. Sensitivity and specificity were 0.67 and 0.95, respectively. CONCLUSIONS: Symptomatic patients with TM exhibited an incidence of testicular neoplasm greater than that of the general population. An algorithm for the surveillance of patients with TM should be developed. The fact that our patient population was symptomatic at referral preselected toward a higher incidence of TM and testicular neoplasm compared to accepted incidence in the general population. Further investigation will require a multicenter trial to generate an adequate patient pool due to the low incidence of TM and testicular malignancy.

Treatment of primary insomnia.

Ten percent to 40% of adults have intermittent insomnia, and 15% have long-term sleep difficulties. This article provides a review of the classification, differential diagnosis, and treatment options available for insomnia. We performed a MEDLINE search using OVID and the key words "insomnia," "sleeplessness," "behavior modification," "herbs," "medicinal," and "pharmacologic therapy." Articles were selected based on their relevance to the topic. Evaluation of insomnia includes a careful sleep history, review of medical history, review of medication use (including over-the-counter and herbal medications), family history, and screening for depression, anxiety, and substance abuse. Treatment should be individualized based on the nature and severity of symptoms. Nonpharmacologic treatments are effective and have minimal side effects compared with drug therapies. Medications such as diphenhydramine, doxylamine, and trazodone can be used initially, but patients may not tolerate their side effects. Newer medications such as zolpidem and zaleplon have short half-lives and minimal side effects. Both are approved for short-term use in the insomniac.

Evaluation of interns by senior residents and faculty: is there any difference?

INTRODUCTION: Both senior residents and faculty members evaluate family practice interns (PGY-1) on the inpatient family medicine service at the University of Missouri-Columbia. The purpose of this study was to investigate the content and nature of narrative comments on a clinical evaluation sheet. METHODS: Objective 1. The authors placed the subjective comments made by faculty and senior residents in their evaluations of PGY-1 residents into 12 distinctive categories. Objective 2. Comments were coded with a positive or negative valence. Objective 3. The genders of the evaluator and learner were recorded. RESULTS: All evaluations made between 1996 and 1999 were analysed. A total of 1341 individual comments were reviewed. Objective 1. Categories used most often were generic comments (20.2%), personal attributes (18%), and clinical competence (14.1%). There was no difference in category use based on the experience level of the evaluator (P = 0.17). Objective 2. The majority of the comments (81.9%) were positive in nature. Senior faculty members were significantly less likely to make negative comments than were junior faculty members or senior residents (P = 0.004). Objective 3. There were no differences in category use based on the gender of the evaluator (P = 0.13). CONCLUSIONS: Objective 1. Narrative evaluation comments may be placed into 12 distinctive categories. Most comments are generic and do not help to inform learning. Objective 2. A total of 82% of comments were positive. Residents were more likely to make negative comments than senior faculty members. Objective 3. There was no demonstrable gender bias in writing negative comments.

The University of Missouri Rural Obstetric Network: creating rural obstetric training sites for a university-based residency program.

This paper describes a rural obstetric experience that was developed for a university-based family practice residency program and designed to increase the number of deliveries per resident, the number of graduates practicing in rural areas, and the number of graduates doing obstetrics. Rural hospitals can be a source of deliveries for residency training programs. This rural obstetric experience also offers more training months in a rural setting and more months training with family physicians.

Promoting postpartum exercise: an opportune time for change.

The postpartum period is an ideal time for clinicians to promote the importance of physical fitness, help patients incorporate exercise into lifestyle changes, and encourage them to overcome barriers to exercise. New responsibilities, physical changes, and competing demands for time may make exercise seem impossible. By emphasizing weight control, stress reduction, and other benefits, clinicians can help new mothers establish healthy exercise goals for the rest of their lives.