Family Medicine Update

Are entering obstetrics/gynecology residents more similar to the entering primary care or surgery resident workforce?

Am J Obstet Gynecol. 2007 Nov;197(5):536.e1-6

Authors: McAlister RP, Andriole DA, Brotherton SE, Jeffe DB

OBJECTIVE: We compared demographic characteristics of first-year residents entering obstetrics/gynecology with those entering primary care and surgery. STUDY DESIGN: We analyzed first-year residents from the 1997-2004 National Graduate Medical Education Census. Multivariable logistic regression models identified independent associations between obstetrics/gynecology residency (compared with primary care and surgery) and demographic predictor variables. RESULTS: More than 90% of studied programs completed the National Graduate Medical Education Census for 146,174 first-year residents. Graduates of US allopathic medical schools, women, African Americans, and entering residents in 2003 and 2004 were more likely to enter obstetrics/gynecology than primary care; Asians were less likely to enter obstetrics/gynecology than primary care. Women, African Americans, and Hispanics were more likely to enter obstetrics/gynecology than surgery; trainees who were Asian, “other” race/ethnicity, and entered residency from 1999-2004 were less likely to enter obstetrics/gynecology than surgery. CONCLUSION: Demographic characteristics of incoming obstetrics/gynecology-residents differed significantly from both primary care and surgery residents. Obstetrics/gynecology should be a unique category in physician workforce studies.

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Guidelines for Adolescent Depression in Primary Care (GLAD-PC): II. Treatment and ongoing management.

Pediatrics. 2007 Nov;120(5):e1313-26

Authors: Cheung AH, Zuckerbrot RA, Jensen PS, Ghalib K, Laraque D, Stein RE,

OBJECTIVES: To develop clinical practice guidelines to assist primary care clinicians in the management of adolescent depression. This second part of the guidelines addresses treatment and ongoing management of adolescent depression in the primary care setting. METHODS: Using a combination of evidence- and consensus-based methodologies, guidelines were developed in 5 phases as informed by (1) current scientific evidence (published and unpublished), (2) a series of focus groups, (3) a formal survey, (4) an expert consensus workshop, and (5) revision and iteration among members of the steering committee. RESULTS: These guidelines are targeted for youth aged 10 to 21 years and offer recommendations for the management of adolescent depression in primary care, including (1) active monitoring of mildly depressed youth, (2) details for the specific application of evidence-based medication and psychotherapeutic approaches in cases of moderate-to-severe depression, (3) careful monitoring of adverse effects, (4) consultation and coordination of care with mental health specialists, (5) ongoing tracking of outcomes, and (6) specific steps to be taken in instances of partial or no improvement after an initial treatment has begun. The strength of each recommendation and its evidence base are summarized. CONCLUSIONS: These guidelines cannot replace clinical judgment, and they should not be the sole source of guidance for adolescent depression management. Nonetheless, the guidelines may assist primary care clinicians in the management of depressed adolescents in an era of great clinical need and a shortage of mental health specialists. Additional research concerning the management of youth with depression in primary care is needed, including the usability, feasibility, and sustainability of guidelines and determination of the extent to which the guidelines actually improve outcomes of youth with depression.

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A mixed methods study to compare models of spirometry delivery in primary care for patients at risk of Chronic Obstructive Pulmonary Disease.

Thorax. 2007 Nov 16;

Authors: Walters JA, Hansen EC, Johns DP, Walters EH, Blizzard L, Wood-Baker R

BACKGROUND: To increase recognition of airflow obstruction in primary care, we compared two models of spirometry delivery for a target group, namely smokers and ex-smokers aged over 35. METHODS: A 6 month qualitative/quantitative cluster randomised study in 8 practices compared opportunistic spirometry by “visiting trained nurses” (TN) with optimised “usual care”(UC) from GPs. Outcomes were: spirometry uptake and quality, new diagnoses of Chronic Obstructive Pulmonary Disease (COPD) and GPs’ experiences of spirometry models. RESULTS: In the eligible target population, 531/904 (59%) patients underwent spirometry in the TN model and 87/1,130 (8%) patients in the UC model (p<0.0001). ATS spirometry standards for acceptability and reproducibility were met by 76% and 44% of tests in the TN and UC models respectively (p<0.0001). 125 (24%) patients tested with the TN model and 38 (68%) with the UC model reported a pre-existing respiratory diagnosis (p<0.0001). In patients with demonstrated airflow obstruction, 3 months after spirometry doctor-recorded COPD increased by 8% (to 19%) in practices with the TN model and by 9% (to 42%) in practices with the UC model, while 60% and 29% respectively had no doctor-recorded diagnosis of either asthma or COPD (p<0.0001). GPs valued the high quality spirometry testing in patients at risk of COPD in the TN model. They identified limitations, including the need for systematic follow up and support with spirometry interpretation, which may explain persistent under-diagnosis of COPD found in practice records. CONCLUSIONS: Although opportunistic testing by visiting trained nurses substantially increased and improved spirometry performance compared to usual care, translating increased detection of airflow obstruction into diagnosis of COPD requires further development of the model. Trial Registration Australian Clinical Trials Registry: registration number 12605000019606.

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