Does family practice at residency teaching sites reflect community practice?

Journal of Family Practice, Dec, 1993 by Valerie Gilchrist, Rebecca S. Miller, William R. Gillanders, Dewey C. Scheid, Everett E. Logue, Donald C. Iverson, Allison M. Oprandi, David L. Weldy, Mark A. Krell

Background. Family medicine has aspired to train residents and conduct research in settings that closely resemble community practice. The purposre of this study was to compare the patient characteristics of the ambulatory teaching centers of a consortium of seven community-based university-affiliated familyu practice residency programs in northeast Ohio with the National Ambulatory Medical Care Survey (NAMCS) results for family physicians (FPs) and general practitioners (GPs).

Methods. Ninety-eight faculty and resident physicians at the residency training site of the Northeastern Ohio Universities College of Medicine collected data on all ambulatory patient visits (N = 1498) for one randomly chosen week between July 1, 1991, and June 30, 1992. We compared these data with patient visits reported in the 1990 NAMCS for FPs and GPs.

Results. The residency training sites saw slightly more children, women, blacks, and Medicare and Medicaid patients. The most common reason for an office visit in both populations was an undifferentiated symptom. Fifteen of the top 20 "reason for visit" codes were identical, as were 14 of the top 20 diagnoses. More preventive and therapeutic services were offered or performed at our residency training sites but fewer diagnostic services were performed. There were fewer consultations requested at our residency training sites but similar hospitalization rates for patients. The mean duration of visit differed by only 1 minute.

Conclusions. The residency training sites of the Northeastern Ohio Universities College of Medicine provide patient care opportunities similar to those found in a national survey of family and general practitioners.

The ambulatory care center has become an increasingly important site for the medical education and research in the United States.[1-4] Technological advances and changes in payment systems have moved patient care from the hospital to the outpatient setting.[5-6] This shift has prompted critical review of many aspects of ambulatory care. These include efficiency, cost effectiveness, faculty time and support, curricula, case mix, and clinical experience.[7-13]

The primary setting for the training of family practice residents is the family practice center.[14] Under faculty supervision family practice residents provide continuing comprehensive care for an assigned panel of patients throughout their 3-year residency. This active "real life" practice attempts to prepare residents for the realities of independent practice.[15-17]

Family medicine has criticized prior medical research from tertiary care centers because of the selection bias. Is our research from family practice teaching sites also biased? How similar are the patients and the practice patterns of an ambulatory teaching unit to those of practices in the community? Holloway[18] has recently questioned the assumption that studies from teaching ambulatory sites are not representative of community practice. There are few empirical data to either support or refute the assumption. The generalizabilityu of clinical research findings from ambulatory teaching sites depends on the demonstration of similarities in patient profile and management between the ambulatory teaching site and the community family practice.

Few studies have compared the practice profiles of family practice teaching sites and community family physicians. The original Virginia study[19] published in 1976 first described the content of family medicine. This study showed comparability between the content of teaching and nonteaching practices by diagnostic category. A later study by Rosenblatt and colleagues[20] described the structure and content of family practice but did not include family practice teaching sites. Allsbury et al[21] compared the patient profiles of 35 senior residents in six family medicine teaching sites during the academic year 1985-1986 with the practice profile of family physicians and general practitioners in the National Ambulatory Medical Care Survey (NAMCS) off 1980-1981. Patients seen by residents were younger, had fewer chronic diseases, and presented more often for acute and pregnancy-related care than did the patients in the national survey. The differing methods of data collection and comparisons made across 5 years limit this comparison. There probably have also been changes in primary care ambulatory practice over the past decade.

The purpose of this study was twofold: (1) to describe the visiting patient characteristics of the family practice residency teaching sites in a consortium of seven community-based university-affiliated family practice residency programs in northeastern Ohio, and (2)_ to compare the patient profile of these teaching sites with the most recent and available (1990) NAMCS findings for ambulatory patients of family physicians and general practitioners.

Methods

The National Ambulatory Medical Care Survey is a nationwide probability survey of health providers designed to provide objective information about ambulatory medical services in the United States. The NAMCS is a continuous survey using a sample of physicians who collect data from a representative sample of their ambulatory office visits for 1 week. The survey addresses the characteristics of ambulatory patients seen in physicians' offices, the nature of their complaints, and their disposition. Patient visits to family physicians (FPs) and general practitioners (GPs) represent, on average, 30% of the ambulatory visits reported in the NAMCS.