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Despite the proven benefits and popularity of hospice, the average hospice patient receives only one month of services before death. Advanced progression of a patient's disease at admission contributes to short lengths of stay, and precludes patients from receiving the full benefit of hospice services. This article uses the results of the literature review to articulate reasons for delayed enrollment and to advance suggestions for ameliorating the problem of short stay in hospice.

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BACKGROUND AND OBJECTIVES: Despite a growing need for family practice to contribute to the national primary care research agenda, the specialty is ill-equipped to assume a more active role. Information about residency programs that are successful in research is a valuable resource for increasing family medicine's research capacity. METHODS: A three-stage investigation was completed in May 1996, consisting of 1) a telephone survey of family practice residency program directors, 2) a mail survey of recent graduates from relatively successful programs identified in stage 1, and 3) in-depth interviews with the program directors or research directors identified by combining data from the first two stages. RESULTS: Most residents in the programs included in stage 2 completed a research project (68.7%) and currently have an interest in practice-based research (57.2%). Residents from programs selected for the study's final stage were more likely to have published a research article (32% versus 20.3%) and to have completed a project while a resident (81% versus 60.1%) than those from the programs not selected. Virtually unanimous characteristics of successful programs include program director support of research, time for research, faculty involvement, a research curriculum, professional support, and opportunities for presenting research. CONCLUSIONS: Individual family practice residencies can be considered to be at one of three levels with respect to their level of research activity: 1) relatively undeveloped, 2) developing, or 3) relatively developed. Programs can expect successful results if they make research a priority, and means are needed for communicating successful strategies between programs.

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Although the available evidence indicates that African-American males are at risk for developing prostate cancer, little is known about the level of awareness among African Americans about prostate cancer or how receptive they are to screening. This study examined the level of knowledge African-American males have about prostate cancer and the factors affecting knowledge levels. Face-to-face interviews were conducted among a sample of African-American males older than 25 years. All respondents were asked if they knew what prostate cancer was (N = 897), and those older than age 40 (N = 556) answered a series of seven questions related to prostate cancer. An index was created that reflected respondents level of knowledge about prostate cancer. Slightly more than 19% of the sample scored relatively high on the index related to prostate cancer knowledge, but 30% answered three or fewer questions correctly. Income, marital status, education, and type of insurance were significantly related to a respondent's level of knowledge. Having a regular physician and discussing prostate screening with a physician were both positively related to a respondent's level of understanding. This study indicates that African-American men do not have adequate knowledge about prostate cancer. Although many African Americans may be getting the prostate cancer message, educational efforts need to be strengthened to reach the less affluent and the less educated. These findings also raise questions about why more African-American men are not being screened and why more primary care physicians are not discussing prostate cancer with their African-American patients.

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BACKGROUND AND OBJECTIVES: The culture of family practice training programs does little to convince residents that research is a worthwhile and important activity. The traditional dichotomy between research and clinical medicine persists today, despite an identified clinical mission for research. METHODS: As part of an effort to build the research capacity of family practice training programs, a telephone survey was administered in August 1995 to the program directors of all residency programs listed in the American Academy of Family Physicians 1995 Directory of Family Practice Residency Programs. The directors were asked about their program's research environment, features designed to promote research activity, and the level of resident research productivity. RESULTS: More than half (53.6%) of the program directors felt that their training program actively promotes research. Three out of four indicated that involving residents in research is a goal of their program. However, only four of 10 (40.8%) programs provide specific time for research, and family practice residents appear to be relatively inactive by conventional measures of research productivity. CONCLUSIONS: Research appears to be developing a limited role in family practice training programs. Resident research productivity remains relatively low and may be a result of residency programs not providing specific time for participating in research. However, the program directors' supportive attitudes may contribute to research and scholarly activity becoming an integral part of a family physician's training.

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OBJECTIVE: To examine the relationship between age and condom use among women who are typically seen in the primary care setting. DESIGN: Survey of a population using a self-administered questionnaire. SETTING: Four community-based family practice clinics located in a low-income, racially mixed geographical area. PATIENTS: All consenting patients (N = 995) during their visits for routine Papanicolaou tests. The mean age of patients was 35 years, with a range of 75 years (12 to 87 years). Respondents were predominantly black (63.2%), 39.2% were single, and over 65% had incomes no greater than $15,000/y. MAIN OUTCOME MEASURE: The outcome measure of condom use is reported. Data analysis of patients' sexual behavior revealed that older women might be at risk for sexually transmitted diseases (STDs). The hypothesis that condom use is related to age emerged during data collection. RESULTS: Condom use is related to being younger (< 31 years), having had an STD, having a sexual partner in whom an STD was diagnosed, having a lower income, or being single or black. In multivariate models, marital status (single), age (< 31 years), and having a partner with an STD remain significant. Among unmarried women, the effects of age, race, and a partner with STD remain, and being a nonsmoker is also significant. In the multivariate analysis for unmarried women, only age (< 31 years) is significantly related to condom use. An independent random sample of charts revealed that almost 45% of the patients aged 45 years or younger received condom counseling, whereas condoms were discussed with none of those older than 45 years. CONCLUSIONS: Because older patients (those beyond child-bearing years) are less likely to use condoms and evidently receive little education about condom use, older patients must be educated about the need for condoms.

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BACKGROUND: There is a growing consensus that an improved research environment is needed for family medicine to continue to evolve. At the same time, there is relatively little discussion about practical ways to implement such an environment. Many believe that our efforts in this area lag far behind our accomplishments in education, training, and the practice of family medicine. PROGRAM DESCRIPTION: This manuscript discusses one community-based academic department's experience in formulating and implementing a research program. By slowly involving faculty in research and by instructing and encouraging residents, a research environment can be incorporated into a residency program's routine. The approach described in this manuscript is evolutionary and relies on committing resources to research while slowly involving faculty and residents in the process. PROGRAM EVALUATION: Measures of research output (funding, publishing in refereed journals, and presenting at professional conferences) suggest that the program has achieved some momentum in the area of research. Although relatively modest by the standards of some university-based programs, the program's achievements demonstrate that a community-based, university-affiliated program can initiate a viable research effort. CONCLUSIONS: Our experience has taught us that implementing a research program is a relatively lengthy process comprised of multiple components. First, individual projects typically consist of a process of funding, presenting, and publishing. Sharing research results with colleagues locally and at professional meetings is an especially important socialization component of research and scholarship. Second, it is important to use refereed and nonrefereed journals as outlets for scholarship, since the process of writing is itself important, especially for family physicians who lack formal research training. Finally, funding proposals and publications almost always require revision and resubmission, a process which contributes to creating and further refining the skills needed by successful researchers.

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BACKGROUND: In effect since 1991, the Patient Self-Determination Act (PSDA) requires that institutions receiving government insurance payments document that they have informed patients of their right to decide on life-preserving measures. Implementing the PSDA should make discussion of advance directives a routine part of acute care hospital admissions. Yet the proportion of those actually completing advance directives such as living wills remains relatively small. METHODS: A telephone survey questionnaire was administered to patients who were hospitalized before and after the implementation of the PSDA. Survey questions probed patient knowledge about living wills and behavior toward obtaining living wills. RESULTS: Patient knowledge about advance medical directives correlated positively with race (white), income (> or = $10K), and level of education (high school or more). Moreover, a significantly greater number of patients hospitalized after implementation of the PSDA knew about living wills than the number of those hospitalized before the Act's implementation. However, actually obtaining a living will correlated positively with age (> 36 years) alone, and implementation of the PSDA was not related to the number of patients who obtained a living will. CONCLUSIONS: Although the study results show that the measures the hospital in the study used to meet PSDA requirements increased patient awareness of living wills, they failed to increase the number of patients who act on this awareness. This finding indicates that simply informing patients about their right of self-determination is insufficient to meet the intended goals of the legislation.

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OBJECTIVE: This case-control study proposed to define risk factors for progression of cervical disease beyond an atypical level, and to explore the possibility of a clinical tool that would aid the clinician in deciding on the need for colposcopy. METHODS: Twenty-three hundred (2,300) abnormal Papanicolaou smears were reviewed to identify documented cases of class II Papanicolaou smears that had progressed. Controls were randomly chosen for each case from the remaining pool of available class II Papanicolaou smears that did not progress. Data analyses were conducted to determine the predictive value of information that would be in a patient's chart with respect to progression from class II Papanicolaou smear to a higher level of disease. RESULTS: A univariate analysis revealed several significant variables, including age, education, attendance at a public clinic, marital status, notification of Papanicolaou results, and a history of sexually transmitted disease. Next, a multivariate analysis demonstrated that a group of significant variables could not be defined, and only notification of an atypical Papanicolaou smear was significant. CONCLUSIONS: The study's findings suggest that the data available in a patient's medical record are not sufficient to develop a risk assessment scale and provide evidence of the need for continued study in this area.

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The recommendations of the expert panel of the National Cholesterol Education Program (NCEP) have been endorsed by national medical organizations as standards for the detection and treatment of hypercholesterolemia, yet information on how these recommendations are being followed in primary care settings is limited. This study was done to determine how family physicians in four primary care clinics associated with a teaching hospital in a large southern city follow the NCEP guidelines. Of the total patient sample (N = 817), about 60% had at least one total serum cholesterol measurement. Patients in the younger age groups were less likely to have a cholesterol determination than older patients. Of those in the "self-pay" category only 33% had a cholesterol determination. Variability by clinic and provider type was also noted, with physician assistants showing the highest compliance with screening guidelines (75%), whereas only 43% of patients seen by family practice residents had a cholesterol measurement. Of patients who should have had a lipoprotein analysis, based on total serum cholesterol and risk factors, only 23% actually had a lipid profile. Our study and other similar ones point out that case finding varies considerably and that efforts to improve case finding need to continue.

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