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This volunteer-based community health advisory program illustrated the benefits of using focus groups to monitor and guide program development. Three focus groups, conducted by program evaluators, obtained input regarding the role of community volunteers. Focus group findings confirmed some of the assumptions held by program developers but refuted others. For example, prospective community participants and program developers were found to view the role of "volunteer" in the neighborhood health advisory program differently. As a result, adjustments were made in recruitment strategies and other procedural aspects to accommodate the residents' perspectives and values. This experience illustrated how preliminary focus group research can enhance linkage between program developers and community members.

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The purpose of this study was to ascertain the extent to which nurse practitioner (NP) education programs are addressing curriculum topics related to practice competencies needed for the next century as recommended by the Pew Health Professions Commission and other professional organizations, including the American Association of Colleges of Nursing and the National Organization of Nurse Practitioner Faculties. The study was part of a comprehensive survey of 11 health professions education programs. NP program directors indicated greatest dissatisfaction with curriculum coverage of "use of electronic information systems" and "business management of practice." The three most important curriculum topics identified by respondents were "primary care," "health promotion/disease prevention," and "effective patient-provider relationships/communication," identical to the three topics rated most important by all groups combined. The most significant barriers to change identified by the respondents included "an already crowded curriculum" and "limited availability of clinical learning sites." Findings show that NP program directors perceive that they are doing an effective job addressing most of the 33 curriculum topics, but they also recognize a need to continue to improve their curricula in response to the ever-changing health care environment. Barriers to achieving the desired curricular improvements, however, may be significant. Recommendations for overcoming these barriers to change are offered.

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The social, legal and ethical implications of advances in biomarker indentification have been discussed by scholars and environmental researchers, but not by the "everyday" professionals and workers who may eventually make and be affected by decisions about their workplace applications. Through the use of a hypothetical scenario, this study introduced members of various professional and occupational groups to the potential uses of biomarkers research on biological monitoring in the workplace. The purpose was to obtain opinions about how events would proceed based on the scenario, leading to a broad discussion of potential uses and abuses of biomarker-based health monitoring. Six professionally homogeneous focus groups, comprised of 1) company health professionals, 2) third-party payers, 3) attorneys, 4) human resource managers, 5) non-unionized workers, and 6) unionized workers, participated in focus groups presented as "think-tank" discussions in Greenville and Charleston, S.C. Participants were given a fictitious "newspaper article" about the use of biomarker-based monitoring at a chemical plant and were asked to comment on what they thought would happen next. The discussion expanded to a general consideration of biological monitoring and its legal, social and ethical ramifications. Data was analyzed through the "immersion/crystallization" method. Few participants reported any knowledge of biological monitoring prior to the focus group session. Some had initial difficulty understanding the concept and how it differs from other means of measuring environmental risk. Although biological monitoring was previously unknown to many participants, occupational groups were relatively consistent in the issues they raised about its use in the workplace. In all groups, questions about potential discrimination against employees were raised. The general consensus was that the use of biomarker-based monitoring would result in conflict and litigation without regulations to protect employees from discrimination. Although most participants saw potential health benefits resulting from the preventive advantages associated with this technology, their concerns about its misuses were paramount. Perceptions varied as a function of occupation. Non-unionized workers expressed the most concern about discriminatory uses of biological monitoring. Unionized workers, who said they believed the union would support their interests, expressed much less concern. Health professionals (company physicians and nurse practitioners) were most alarmed about the "extra work" a monitoring program would create for them. Human resource managers concentrated on the company's "damage control" efforts. Attorneys emphasized that the reliable use of such tests would establish a causal relationship between exposure and personal injury. The results of this project illustrate that people who are most likely to be affected by biomarker-based biological monitoring in the workplace readily understand and are alarmed by its legal and ethical implications. It is unlikely that this technology will be fully accepted as an environmental risk assessment tool or as a prevention strategy without stringent protection of workers' rights. This study demonstrated the value of focus groups in obtaining opinion data about an environmental risk issue that it not yet well known to the general public.

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The purpose of this study was to determine the extent to which nurse-midwifery education programs are addressing the practice competencies that have been recommended by the Pew Health Professions Commission and others as essential for effective practice in the 21st century. This study was part of a larger survey of eleven health professions education programs. The 56 nurse-midwifery program directors whose names and addresses were provided by the American College of Nurse-Midwives were surveyed by mailed questionnaire, with a response rate of 59% (n = 33). The study sought to identify current and ideal emphasis placed on 33 broad topics, most important curriculum topics, and barriers to curriculum change as perceived by respondents. Findings revealed that nurse-midwifery program directors would like to see greater emphasis placed on every topic except one (tertiary/quaternary care). Desired increases ranged from .04 to 1.36. The overall mean rating for all topics was 3.51 for current emphasis (5-point scale) and 4.18 for ideal emphasis, both of which were higher than any other survey group. The greatest desired increases (> 1.00) were for "primary care," "managed care," "use of electronic information systems," and "business management of practice." Respondents identified "primary care," "health promotion/disease prevention," and "accountability for cost-effectiveness and patient outcomes" as the most important topics. The top three barriers to curriculum change were identified as "already crowded curriculum," "inadequate funding," and "limited availability of clinical learning sites," the last being statistically significant compared with other survey groups. Findings indicate that nurse-midwifery program directors perceived that they are adequately addressing most of the curriculum topics, while continuing to focus on the need for curriculum change as the health care environment changes.

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This study assessed the current and ideal for dental curriculum emphasis of thirty-three curriculum topic areas and evaluated barriers to curriculum change. A forty-six item survey was mailed to the academic deans of all U.S. dental schools with an 86 percent e response rate (n = 57). The means of their responses for current curricular emphasis and ideal emphasis on the thirty-three topic areas were compared. "Health promotion/disease prevention," "primary care," and "effective patient-provider relationships/communication" were the three topic areas rated most highly (for ideal emphasis) by the academic deans. "Case management," "outpatient/ambulatory care," and "continuous quality improvement" also received high mean scores for ideal emphasis. The most significant barrier to curriculum reform was "an already crowded curriculum." The academic deans reasserted the traditional emphasis in dentistry on primary care. There also appears to be considerable support for educational programs that will foster better patient relationships and greater quality assurance and control.

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PURPOSE: To determine which of 33 topics academic deans identify as worthy of greater emphasis in medical curricula. Also, to assess the barriers to needed curricular changes. METHOD: In March 1996 a questionnaire was developed and mailed to the academic deans of all U.S. schools affiliated with the Association of American Medical Colleges (n = 126) and all schools associated with the American Association of Colleges of Osteopathy (n = 17). There were 46 questions in a five-point Likert-type format (1 = not at all, 5 = to a great extent) and one open-ended question. The deans were queried as to what extent each of 33 topics (1) was included in medical students' required learning experiences (current emphasis) and (2) should be included in medical students' required learning experiences (ideal emphasis). The deans were also asked to what extent they believed 12 different factors would be barriers to needed curriculum changes in their programs. Primary data analysis focused on simple comparisons of response means and frequencies. RESULTS: Two separate mailings resulted in the return of 100 questionnaires (70%): 85 from the allopathic schools (67%) and 15 from the osteopathic schools (88%). "Effective patient-provider relationships/communication," "outpatient/ambulatory care," and "health promotion/disease prevention" had the three highest mean ratings for ideal emphasis by the allopathic school deans. "Primary care," "professional values," and "use of electronic information systems" also had high mean rankings for ideal emphasis. "Primary care," "outpatient/ambulatory care," and "health promotion/disease prevention" had the three highest mean ratings for ideal emphasis by the osteopathic school deans. CONCLUSION: Changes in health care delivery and an increasing generalist orientation are influencing academic deans' perspectives on needed curriculum changes, and there appears to be considerable support for medical school curricula that will foster a broader, more humanistic role for physicians.

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Because of widespread public and governmental concern about the health effects of environmental hazards and exposure in recent years, and the increasing incidence of environmentally induced diseases, it is important that primary care nurse practitioners possess the knowledge and skills to effectively address environmental health as a component of their practice. A mailed questionnaire survey of 187 United States' nurse practitioner (NP) programs was conducted, with a response rate of 64%, to determine: 1) current and ideal emphasis on environmental health, 2) faculty preparation for teaching environmental health, 3) environmental health competencies expected of graduates, 4) didactic and clinical contact hours devoted to environmental health, and 5) barriers and incentives to greater emphasis on environmental health. Findings reveal that more than two thirds of NP program directors believe there should be greater emphasis on environmental health in their programs, but expressed concerns about overcrowded curricula and lack of faculty preparation as barriers to change. Competencies with the highest mean ratings included understanding the relationship between environmental hazards and human health, accessing information resources related to environmental hazards and health, and counseling clients about how they can reduce risks associated with environmental hazards. The two factors identified as most likely to increase the emphasis on environmental health in NP programs were having nurse faculty with expertise and being able to access information resources related to environmental health. Currently, insufficient attention is given to environmental health in NP education programs.

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Because of widespread public and governmental concern about the health effects of environmental hazards and exposure in recent years, and the increasing incidence of environmentally-induced diseases, it is important that primary care nurse practitioners possess the knowledge and skills to effectively address environmental health as a component of their practice. A mailed questionnaire survey of 187 U.S. nurse practitioner (NP) programs was conducted, with a response rate of 64%, to determine: 1) current and ideal emphasis on environmental health, 2) faculty preparation for teaching environmental health, 3) environmental health competencies expected of graduates, 4) didactic and clinical contact hours devoted to environmental health, and 5) barriers and incentives to greater emphasis on environmental health. Findings reveal that more than two-thirds of NP program directors believe there should be greater emphasis on environmental health in their programs, but expressed concerns about overcrowded curricula and lack of faculty preparation as barriers to change. Competencies with the highest mean ratings included understanding the relationship between environmental hazards and human health, accessing information resources related to environmental hazards and health, and counseling clients about how they can reduce risks associated with environmental hazards. The two factors identified as most likely to increase the emphasis on environmental health in NP programs were having nurse faculty with expertise and being able to access information resources related to environmental health. Currently, insufficient attention is given to environmental health in nurse practitioner education programs.

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BACKGROUND: The Institute of Medicine and the American College of Physicians have advocated that physicians broaden their participation in the environmental aspects of medical care. Accordingly, both organizations recommend training of future primary care physicians for greater competency in and appreciation of this area of medicine. This study assessed the present emphasis on environmental health in family practice residency programs by examining the extent program directors expect graduates to have specific competencies in environmental medicine. METHODS: A written survey was mailed to directors of all 393 family practice residency programs listed in the 1993 Directory of Family Practice Residency Programs. Respondents were asked to indicate the extent to which each of eight environmental health competencies was expected of their graduates. The list of environmental health competencies was based on the literature and on interviews with family practice educators. Perceptions about the "present" and "ideal" environmental health emphasis in their programs were also measured. RESULTS: A total of 262 completed surveys were returned for a response rate of 67%. Respondents reported that they expected their graduates to have general knowledge of and competence in environmental health areas that pertain to patient care. Competencies with social and political implications were least likely to be expected. Two thirds of respondents indicated that "minimal emphasis" is presently placed on environmental health. Seventy percent indicated that the "ideal" amount of emphasis placed on this topic is "moderate." CONCLUSIONS: This survey's results suggest that family practice residency program directors expect their graduates to know basic environmental health concepts and be skilled in related aspects of patient care. The development of environmental health training programs must take into account that environmental health may be viewed as a topic of secondary importance and that in most residencies, faculty expertise in this area is limited. For this reason, a self-tutoring strategy, aimed toward the educational needs of both faculty and residents, is recommended.

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OBJECTIVE: Substantial evidence supports the concept that residency training is physically and emotionally stressful. However, few studies have examined resident health. This study measured the physical and psychological health of family practice residents and compared these results with population norms. METHODS: This cross-sectional, descriptive study used physical health measures of weight, blood pressure, skin-fold thickness, serum cholesterol, and aerobic exercise capacity. Psychological measures included the Beck Depression Inventory, the State-Trait Anger Expression Inventory, the State-Trait Anxiety Inventory, and the Ways of Coping Questionnaire. A demographic and lifestyle questionnaire was also administered. Data were collected on 178 residents in seven family practice residency programs in South Carolina. RESULTS: Physical health measures show that residents are indistinguishable from age-specific population norms. Psychological testing revealed excellent coping skills with clinically significant psychological symptoms noted in only one of the 178 residents. CONCLUSION: This study provides evidence that despite the rigors of residency training, family practice residents in South Carolina have average physical health and better-than-average psychological health, according to age-adjusted population norms. These results suggest that the coping skills of family practice residents are well suited to the stresses of family practice residency training.

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BACKGROUND: Despite the National Institute of Medicine's endorsement of computer-based patient records (CPRs), the majority of family practice residency programs continue to use paper records. This study examined the perceptions of family medicine educators about CPRs to understand their limited use of computerized patient record systems. METHODS: A survey was mailed to the directors of 247 family practice residency programs; 199 were completed and returned (response rate 81%). Respondents were asked to identify their concerns about CPRs, what they perceived as the advantages and disadvantages of CPRs compared with paper records, and the likelihood that their program will implement a CPR within the next year and within the next 5 years. RESULTS: The perceived benefits of CPR were greater efficiency, accuracy, and quality in patient care. However, many respondents were concerned about cost, mechanical breakdowns, conversion hardships, training needs, and physicians' attitudes. Despite these objections, the majority of respondents reported it is ¿somewhat¿ or ¿very¿ likely that their program will implement a CPR system within the next 5 years. CONCLUSIONS: Although the surveyed family medicine educators believed that CPRs offer significant benefits, they also perceived several disadvantages of converting from paper to computer-based patient records. Widespread use of CPRs among family practice programs in the near future depends on the extent to which vendors and others heighten awareness and knowledge about the benefits of CPRs and address concerns about cost, mechanical breakdowns, and transition difficulties.

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Academic deans at 126 US medical schools were surveyed in Spring 1994. Comparisons of means and frequencies, multiple regression, and factor analysis were used. Study results showed only low to moderate expectations for graduate competence in seven environmental health competency areas. Over two-thirds of deans (70%) indicated that there was "minimal" emphasis on environmental health at their schools; 61% thought that ideally there should be "moderate" emphasis. An "already crowded curriculum" and "too few qualified faculty" were frequently cited as barriers to greater emphasis on environmental health. Students were identified most commonly as the group expressing the greatest support for environmental health education. Although there was not a clear consensus, occupational medicine departments were most often selected as best suited to offer environmental medicine education.

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BACKGROUND: The purpose of this study was to examine specific factors that motivated the request for early removal of Norplant among a group of young, low-income women who were dissatisfied with this contraceptive method. METHODS: Focus groups were conducted to obtain qualitative in-depth attitude and opinion data about Norplant from women who had used this method of contraception for a period ranging from 2 months to 25 months and had requested its removal because of side effects. RESULTS: Patient motivation for requesting Norplant removal was based on side effects. No other reason for early removal requests emerged from the focus group discussions. However, the comments of many participants raised questions about the psychosocial context in which patients obtain information about Norplant and request early removal. Many participants mentioned having felt pressured to accept Norplant and not being fully informed about possible side effects. All but two said they were encouraged to "wait out" side effects and that physicians were reluctant to remove the Norplant capsules. Many participants recalled that they had to request removal several times before their physicians complied with their wishes. CONCLUSIONS: The results of this study suggest that there is a need to review the process of educating patients about Norplant, the situational context of Norplant counseling, and physician practices related to patients' requests for early removal.

PIP: Focus group discussions were utilized to increase understanding of the factors associated with Norplant discontinuation among young, low-income women and identify counseling needs. The 15 participants--all of whom had requested Norplant removal after at least two months of use--were drawn from health clinics in three South Carolina cities. Group participants were 18-26 years old; the mean duration of Norplant use was 13.8 months. Norplant's convenience, effectiveness, long-term duration, and low cost were cited as the major advantages of the method, while prolonged bleeding, headaches, weight gain, hair loss, and mood swings were identified as the worst side effects. These side effects were the reason for requesting early Norplant removal. Although participants had been exposed to a combination of educational methods before Norplant insertion, they noted that the possibility of adverse side effects was minimized. Others felt they had been pressured to agree to Norplant insertion while still in the hospital following a delivery. The majority reported that medical staff responded negatively to their request for removal and were unsympathetic about Norplant-related side effects. As a result, these women developed a mistrust of the medical system. Since young, low-income women comprise a major target population for Norplant use, it is important to develop a counseling protocol that prepares them for side effects and suggests various coping strategies.

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BACKGROUND AND OBJECTIVES: Insufficient attention has been paid to the role that modern information systems can play in improving the delivery of and education about preventive services in family medicine training and practice sites. From September 1990-September 1993, the Department of Family Medicine at the Medical University of South Carolina conducted a demonstration project designed to develop, implement, and evaluate a comprehensive, computer-based preventive services delivery and educational system, based on the recommendations in the US Preventive Services Task Force (USPSTF) Report. METHODS: A computer-based patient record (CPR) system was implemented. The system had sophisticated preventive services tracking and reminder, physician, and patient education features. Twenty-nine basic USPSTF recommendations were incorporated in the system. An extensive physician education series was also implemented. A multi-method evaluation system, including patient exit surveys, physician interviews, and practice audits was used to evaluate and design improvements to the CPR and education systems. RESULTS: Although the system initially had no effect on patient perceptions about the frequency of preventive services delivery, there was reasonable concordance between patient desires and physician behavior for the discussion of preventive services (Kappa = .5 to .6). Physician acceptance of the system was good--in 1992, 30% of physicians used the preventive services reminders in most of their patient visits, and in 1993, 88% of physicians reported more frequent use. Practice audits from February 1992-July 1993 showed increased adherence with all seven counseling services, 10 of 15 screening services, and one of five immunization services. CONCLUSIONS: A CPR-based preventive services system coupled with an adaptable physician education about and delivery of preventive services. an ideal solution to improving the education about and delivery of preventive services.

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BACKGROUND: Career choice research has shown that exposing medical students to family medicine, through a special medical school emphasis or a required clerkship, correlates with an increased rate of selection of family practice. It has been hypothesized that actual exposure to family medicine mitigates the negative stereotypes held by many medical students. METHODS: This study used a qualitative strategy to examine how a family medicine clerkship altered medical students' perceptions and attitudes toward this specialty. A series of 12 focus groups were conducted with the students who had just completed a required family medicine junior core clerkship at our institution. RESULTS: Focus group findings confirmed the existence of negative stereotypes about family practice among medical students and provided additional information on their nature and origins. In addition, student comments indicated that a third-year family medicine clerkship experience dispelled this negative stereotyping and instilled in students a greater respect for and interest in family practice. CONCLUSION: Third-year clerkships can enhance students' perceptions of family practice by dispelling negative stereotypes and by providing medical students with a more accurate portrayal of the nature of this primary care specialty.

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OBJECTIVE: To improve the computer-generated preventive services patient reminder letter used by a department of family medicine at a medical university in South Carolina. DESIGN: A qualitative method chosen because of its demonstrated efficacy in generating in-depth attitude and opinion data was used for 12 focus groups (111 participants) in which participants were asked to evaluate the reminder letter and other preventive services reminder materials. Information from these groups was used to design a revised patient reminder system that was tested in six additional focus groups (50 participants). SETTING: University-based family medicine center. PARTICIPANTS: Adults 19 years of age or older of whom approximately one half were selected from a random sample of family medicine center patients and the remainder from volunteers recruited from the general community by newspaper advertisement. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Participants' perceptions and attitudes about the reminder letter and other materials as well as suggestions for improving the preventive services reminder system. RESULTS: The revised patient reminder materials resulted in a warmer, more personal letter sent to patients at the time of their birthdays in an envelope containing a prevention message. A leaflet describing the rationale for preventive services and answering common questions about prevention and a booklet describing the preventive services available at the family medicine center were also developed. CONCLUSION: This study illustrated the benefits of incorporating patients' perspectives in the design of preventive services reminders.

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BACKGROUND: Balint groups are focused discussion groups that help students, residents, or physicians respond empathetically to their patients and recognize underlying psychosocial elements in patients' complaints. Approximately 40% to 60% of residents who start optional Balint group training show infrequent attendance. The primary objective of this study was to interview frequent and nonfrequent attenders to assess the value of Balint group training from the residents' perspective and to explain why many residents attend Balint group meetings infrequently or discontinue Balint training altogether. METHODS: Two methods were used to discern differences between frequent attenders and infrequent attenders: (1) evaluation of Myers-Briggs Type Indicator (MBTI) data collected at the beginning of the residency program, and (2) semi-structured personal interviews with both frequent and infrequent attenders. RESULTS: MBTI data showed frequent attenders to have higher scores than infrequent attenders in the intuitive dimension. Interviews with Balint group attenders showed strong perception about the value of this training. The majority felt Balint training had improved their effectiveness as family physicians, specifically when dealing with troubling patients. Infrequent attenders mentioned scheduling problems and a variety of emotional/personality factors as reasons for not attending Balint seminars. Frequent attenders attributed nonattendance in others to lack of interest in the psychodynamics of the doctor-patient relationship and differences in personality type. CONCLUSION: Residents who participated in Balint groups perceive this training as helpful in understanding themselves in relationships with their patients. However, the study results suggest that many residents choose not to attend optional Balint group seminars because of emotional or personality variables, such as anxiety about self-disclosure and introversion. While Balint groups are a valuable component of a family practice residency program, it is likely that not all residents will be motivated or capable of deriving benefits from this teaching approach.

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BACKGROUND: Despite an emerging consensus as to which preventive services are appropriate, a minority of patients receive them. Although adherence to recommendations for some interventions has increased, research studies have shown that adherence rates can be further improved through a better understanding of patient attitudes and motivations regarding preventive services. METHODS: Using components of the Patient Path Model, this study examined the response to patient reminder letters for cholesterol screening sent to 1077 adult patients between August and October 1990. The research strategy incorporated both quantitative and qualitative methods, including a telephone survey and focus group interviews of nonresponders to the reminder letter. RESULTS: Three hundred seven patients were surveyed by telephone to ascertain their reasons for nonresponse. One hundred fifty-four (50.2%) did not recall receiving the reminder letter, 84 (27.4%) recalled receiving the letter but did not recall its content, and 69 (22.5%) recalled both receiving the letter and its content. No consistent reason for nonadherence emerged among the 69 nonresponders who recalled the reminder. Twenty-seven of the nonresponders who did not recall receiving the cholesterol reminder participated in the focus groups. The participants stressed the importance of distinguishing the reminder letter from a bill, conveying a personally relevant message, and addressing logistical barriers to preventive services. CONCLUSIONS: Careful attention to the format and content of patient reminder letters is necessary to improve adherence to preventive services recommendations.

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