Resident and program director perspectives on third-year family medicine programs.

OBJECTIVE: To determine the views of family medicine (FM) program directors, third-year program coordinators, and residents on the factors affecting demand and allocation of postgraduate year 3 (PGY3) positions and the effects of these programs on the professional activities of program graduates. DESIGN: Cross-sectional surveys and key informant interviews. SETTING: Ontario (FM residents) and across Canada (program directors) in 2006. PARTICIPANTS: All FM residents in Ontario and all core program directors and PGY3 program coordinators nationally were eligible to participate in the surveys. Eighteen key informant interviews were conducted, all in Ontario. Interviewees included all FM program directors, selected PGY3 program coordinators, residents, and other community stakeholders. METHODS: Resident surveys were Web-based; invitations to participate were delivered by FM programs via e-mail lists. The program director and coordinator surveys were postal surveys. Interviews were audiotaped and transcribed, and the authors coded the interviews for themes. MAIN FINDINGS: Response rates for the surveys were 34% to 39% for residents and 78% for program directors and coordinators. Respondents agreed that programs should include flexible training options of varied duration. Demand for training is determined more by resident need than community or health system factors, and is either increasing or stable. Overall, respondents believed that approximately one-third of core program graduates should have the opportunity for PGY3 training. They thought re-entry from practice should be permitted, but mandatory return-of-service agreements were not desired. Program allocation and resident selection is a complex process with resident merit playing an important role. Respondents expected PGY3 graduates to practise differently than PGY2 graduates and to provide improved quality of care in their fields. They also thought that PGY3 graduates might play larger roles in leadership and teaching than core program graduates. CONCLUSION: It is likely that PGY3 programs will continue to grow and form an increasingly important part of the FM training system in Canada. Flexible programs that can adapt to changing educational, health system, and community needs are essential. Training programs and national and provincial colleges of FM will also need to ensure that these physicians are provided with opportunities to maintain their links with the rest of the FM community.

Practice patterns of graduates of 2- and 3-year family medicine programs: in Ontario, 1996 to 2004.

OBJECTIVE: To compare patterns of practice between graduates of core 2-year family medicine (FM) training programs and those completing an additional postgraduate year (PGY3) of training. DESIGN: Retrospective cohort study using administrative data from the Ontario Health Insurance Plan. SETTING: Ontario. PARTICIPANTS: Graduates of Ontario FM residency programs from 1996 to 2002 who provided insured services in Ontario for 1 or more fiscal years between 1996 and 2004. MAIN OUTCOME MEASURES: Proportion of physician years of service in which a minimum number of services were provided in each of the following categories: anesthesia, emergency medicine (EM), home visits, hospital visits, nursing home visits, intrapartum obstetrics, palliative care, office-only practice, and rural locations, as well as deciles for proportion of billings for emergency department work and "quasi-specialty" designations based on billing patterns. Results are stratified by type of training and years in practice. RESULTS: Graduates of PGY3 programs are significantly more likely to practise in a range of nonoffice settings than their counterparts who completed core 2-year FM training programs. Differences were the most marked in areas in which additional training had been undertaken, but also extended to other categories. There was no effect on the proportion practising in rural locations, unless the training was undertaken in a rural setting or in anesthesia. Physicians including EM in their practices were more likely to practise mostly or almost all EM if they had undertaken either EM programs or self-directed programs at non-northern training sites. Very few graduates of any type were classified as belonging to a quasi-specialty group, other than those who completed care of the elderly or palliative care (hospitalist) and anesthesia programs. CONCLUSION: Completion of a PGY3 program is strongly associated with increased participation in practice outside the office, particularly in the area of the training provided.

Acute otitis media in children with tympanostomy tubes.

OBJECTIVE: To review evidence regarding antibiotic treatment of acute otitis media in children with tympanostomy tubes and to discuss antibiotic resistance and ototoxicity. QUALITY OF EVIDENCE: MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, and the Cochrane Central Register of Controlled Trials were searched for relevant articles. Articles providing level I evidence(randomized controlled trials) for treatment were used. Key words used in the search included otitis media(MeSH), middle ear ventilation (MeSH), tympanostomy tubes, and otorrhea. MAIN MESSAGE: Tympanostomy tube insertion is a common procedure; acute otitis media is a frequent sequela. Treatment options include systemic or topical antibiotics with or without corticosteroids. The development of bacterial resistance to antibiotics and ototoxicity related to treatment are important considerations. There have been well-conducted randomized controlled trials of topical versus systemic antibiotic agents. Combined with proper ear cleaning and tragal pumping, topical fluoroquinolone agents offer the most effective treatment. CONCLUSION: Current evidence suggests that a topical fluoroquinolone, with or without a corticosteroid, is the treatment of choice for acute otitis media with tympanostomy tubes.

Update on pharmacologic and nonpharmacologic therapies for smoking cessation.

OBJECTIVE: To review the evidence on the efficacy and safety of pharmacologic and nonpharmacologic therapies for smoking cessation. QUALITY OF EVIDENCE: MEDLINE, EMBASE, and the Cochrane Database of Systematic Reviews were searched for randomized controlled trials, meta-analyses, and systematic reviews (level I evidence) pertinent to pharmacologic and nonpharmacologic smoking cessation therapies. MAIN MESSAGE: Pharmacologic smoking cessation aids are recommended for all smokers trying to quit, unless contraindicated. A new pharmacologic smoking cessation aid, varenicline, is now available in Canada. Level I evidence at 1-year follow-up indicates that it is effective for smoking cessation. Adverse effects include nausea, insomnia, and abnormal dreaming. Nausea is mild or moderate and decreases over time. Varenicline is more effective than placebo or bupropion. Counseling also increases the likelihood of achieving cessation. CONCLUSION: Preliminary data indicate that varenicline is more effective than other available pharmacologic smoking cessation aids. Pharmacologic therapy should be combined with nonpharmacologic therapy.