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OBJECTIVE: To evaluate the Grant Generating Project (GGP), a program designed to train and assist family medicine researchers to secure funding as part of an overall strategy to increase research capacity in family medicine. STUDY DESIGN: Cross-sectional mail survey. POPULATION: First- through fourth-year participants in the GGP program starting from 1995. Participants were faculty members of American and Canadian family medicine departments. OUTCOME MEASURED: We measured cardinal features of primary care quality including first-contact care (accessibility and utilization), longitudinality (strength of affiliation and interpersonal relationship), comprehensiveness (services offered and received), and coordination of care. RESULTS: Most (18 of 23) GGP participants completed the survey. A total of 58 grants/contracts were submitted by respondents, representing approximately US$19.3 million. Currently, 17 (29%) are pending, representing $10.8 million (including training grants). Given the current track record, $4.8 million additional grants funds could be generated. GGP strengths cited by respondents included an effort to enhance family medicine research; personal attention, guidance, motivation, and feedback from GGP faculty and mentors; development of grant-writing skills; encouragement to attend family medicine meetings; ability to meet and learn from peers; mock study section experience; and the ability to teach, mentor, and encourage others as the GGP experience did for them. Major challenges cited were a variable degree of commitment from mentors, lack of a long-term commitment to participants, and difficulty accommodating the research focus and skill level of participants. In general, most respondents regarded the GGP program as well worth the time and effort invested. CONCLUSIONS: One to 2 years after participating in the program, participants achieved a remarkable track record of grant submissions. Moreover, the GGP program has had a substantial impact on participants; many are now teaching and mentoring others in their department. If sustained, the program will greatly increase the research capacity of the discipline of family medicine.

BACKGROUND AND OBJECTIVES: Some family medicine residents often doubt their ability to become competent family physicians. Individuals who believe themselves to be less intelligent and less competent than others perceive them to be are described in the psychological literature as having the "impostor phenomenon." This study sought to determine the prevalence of the impostor phenomenon in family medicine residents. METHODS: We conducted a mail survey of all 255 family medicine residents in Wisconsin. The survey included the Clance Imposter Scale and two scales measuring depression and anxiety. RESULTS: A total of 185 surveys were returned, for a 73% response rate. Forty-one percent of women and 24% of men scored as "impostors." Impostor symptoms were highly correlated with depression and anxiety. CONCLUSIONS: About one third of family medicine residents believe they are less intelligent and less competent than others perceive them to be. These residents suffer psychological distress and do not believe they will be ready to practice family medicine after graduation. Teachers may assist these learners by letting them know such feelings are common and by providing regular, timely, and positive feedback.

The results of the 2010 National Resident Matching Program (NRMP) reflect a small but promising increased level of student interest in family medicine residency training in the United States. Compared with the 2009 Match, 75 more positions (with 101 more US seniors) were filled in family medicine residency programs through the NRMP in 2010, at the same time that seven more positions were filled in primary care internal medicine (one more US senior), 14 fewer positions were filled in pediatrics-primary care (16 fewer US seniors), and 16 more positions were filled in internal medicine-pediatrics programs (58 more US seniors). Multiple forces including student perspectives of the demands, rewards, and prestige of the specialty; national dialogue about health care reform; turbulence in the economic environment; lifestyle issues; the advice of deans; and the impact of faculty role models continue to influence medical student career choices. Ninety-four more positions (90 more US seniors) were filled in categorical internal medicine. Fifty-seven more positions (29 more US seniors) were filled in categorical pediatrics programs. The 2010 NRMP results suggest that there is a small increase in primary care careers; however, students continue to show an overall preference for subspecialty careers. Despite matching the highest number of US seniors into family medicine residencies since 2004, in 2010 the production of family physicians remains insufficient to meet the current and anticipated need to support the nation's primary care infrastructure.

BACKGROUND AND OBJECTIVES: The use of an electronic audience response system (ARS) that promotes active participation during lectures has been shown to improve retention rates of factual information in nonmedical settings. This study (1) tested the hypothesis that the use of an ARS during didactic lectures can improve learning outcomes by family medicine residents and (2) identified factors influencing ARS-assisted learning outcomes in family medicine residents. METHODS: We conducted a prospective controlled crossover study of 24 family medicine residents, comparing quiz scores after didactic lectures delivered either as ordinary didactic lectures that contained no interactive component, lectures with an interactive component (asking questions to participants), or lectures with ARS. RESULTS: Post-lecture quiz scores (maximum score 7) were 4.25 +/- 0.28 (61% correct) with non-interactive lectures, 6.50 +/- 0.13 (n=22, 93% correct) following interactive lectures without ARS, and 6.70 +/- 0.13 (n=23, 96% correct) following ARS lectures. The difference in scores following ARS or interactive lectures versus non-interactive lectures was significant (P <.001). Mean quiz scores declined over 1 month in all three of the lecture groups but remained highest in the ARS group. Neither lecture factors (monthly sequence number) nor resident factors (crossover group, postgraduate training year, In-Training Examination score, or post-call status) contributed to these differences, although postcall residents performed worse in all lecture groups. CONCLUSIONS: Both audience interaction and ARS equipment were associated with improved learning outcomes following lectures to family medicine residents.

I want to speak about the future of family medicine as counterculture. Some of us recoil at the use of the language of “reform” and “revolution” to describe our discipline. These are the semantics of violence, and they project an image that we do not feel. We are benevolent, wellintentioned, “humble country doctors” who only want to restore some balance to medicine. We do not want to destroy anything or take anything away from anybody; we just want a place in the sun for ourselves and our residents and students. We are not radicals who wish to turn the world upside down. Indeed, I have sometimes thought that our cumulative effect on the body politic of medicine has been conservative more than liberal or radical. In many ways, by our success, we have taken the heat off the medical profession from the public; therefore, the status quo is being preserved. That is conservative. More radical solutions to perceived problems will not be imposed as long as the public thinks that something is being done. Short-term effects are not the best criteria, however, for determining the social effects of a movement. Neither are the stated objectives of most of the people who participate in it. There are a number of perspectives from which one can analyze the renascence of family practice in the sixth and seventh decades of this century. Quantitatively, it is an unprecedented phenomenon. The numbers of departments, programs, and residents are well known to you. The magnitude of this achievement required the convergence of social, political, economic, and professional forces, over most of which we had (and have) very little control. Many different institutions, organizations, groups, and individuals with differing agendas and expectations have invested heavily in the family practice movement. No one can be given credit for our success. The time was right, the idea was right, and from the perspective of one who has participated almost from the beginning, there has been an aura of serendipity about it all. Most of us have simply responded to opportunities that just seemed to be there. There is a sense of having participated in something that is a great deal bigger than oneself and one’s ideas. Qualitatively, there is a precedent for family practice in pediatrics. That specialty preceded us by 35 years, and many of the forces that created pediatrics are similar. Rosemary Stevens has chronicled the development of medical and surgical specialties in the United States from the late 19th century through the

As many as 90 million Americans have difficulty understanding and acting on health information. This health literacy epidemic is increasingly recognized as a problem that influences health care quality and cost. Yet many physicians do not recognize the problem or lack the skills and confidence to approach the subject with patients. In this issue of Family Medicine, several articles address health literacy in family medicine. Wallace and Lennon examined the readability of American Academy of Family Physicians patient education materials available via the Internet. They found that three of four handouts were written above the average reading level of American adults. Rosenthal and colleagues surveyed residents and found they lacked the confidence to screen and counsel adults about literacy. They used a Reach Out and Read program with accompanying resident education sessions to provide a practical and effective means for incorporating literacy assessment and counseling into primary care. Chew and colleagues presented an alternative to existing health literacy screening tests by asking three questions to detect inadequate health literacy. Likewise, Shea and colleagues reviewed the prospect of shortening the Rapid Estimate of Adult Literacy in Medicine (REALM), a commonly used health literacy screening tool. Both the Chew and Shea articles highlight the need for improved methods for recognizing literacy problems in the clinical setting. Further research is required to identify effective interventions that will strengthen the skills and coping strategies of both patients and providers and also prevent and limit poor reading and numeracy ability in the next generation.

The placebo response is commonly invoked as a factor in the therapeutic relationship between the family physician and the patient, but important recent literature can be difficult for family physicians to access. Coordinated interdisciplinary research into the placebo response as it occurs in primary care settings is lacking. Although there is controversy about the nature and scope of the placebo response, important suggestions are emerging about its psychological mechanisms (expectancy and conditioning) and the biochemical pathways that act as psychosomatic linkages (endorphins, catecholamines and cortisol, psychoneuroimmumunology). The available research justifies interventions by family physicians that maximize the placebo response in everyday patient encounters. These include the sustained partnership approach, working with patients on the narratives they construct to explain illness, listening to patients, providing them with satisfactory explanations, expressing care and concern, and enhancing their sense of control. Notable opportunities exist for family medicine investigators to expand the understanding of this phenomenon.

OBJECTIVE: To compare the effectiveness of three computerized reminder systems in the delivery of five preventive procedures in family practice. DESIGN: Prospective, randomized, controlled study. SETTING: Ottawa Civic Hospital Family Medicine Centre. PARTICIPANTS: Of 8502 patients 15 years of age or more who were not in a hospital or institution 5883 were randomly assigned, by family, to a control group, a physician reminder group (passive) or a telephone or letter reminder group (active). The remaining 2619 patients were not included in the randomized portion of the study but were monitored. INTERVENTION: During 1 year the patients in the active reminder groups received a telephone call or letter reminding them of any overdue preventive procedures; for those in the passive reminder group the physician was reminded at an office visit to provide any overdue service. OUTCOME MEASURE: Rates of completion of the preventive procedures required. MAIN RESULTS: All three reminder systems significantly improved the delivery of preventive services (p less than 0.001). The procedure completion rates were 42.0% in the letter reminder group, 42.0% in the telephone reminder group, 33.7% in the physician reminder group and 14.1% in the randomized control group. The use of a letter was more cost-effective than the telephone system, but the physician reminder system was the most cost-effective. CONCLUSION: Computerized reminder systems do improve the delivery of preventive services in family practice.

To test the hypothesis that depression is significantly underdiagnosed in general medical settings, the Zung Self-Rating Depression Scale was administered to 1,086 family medicine outpatients seen during a 12-month period before their initial medical examination. The effects of such screening on clinical recognition and treatment of depression were examined. Of the 1,086 patients, 143 (13.2%) were symptomatically depressed. These patients were randomized into two groups: 102 were identified as clinically depressed to their physician, and the remaining 41 were not (control group). Physicians diagnosed depression in 15% of the control group and in 68% of the identified group. At 4-week follow-up, 64% of the identified patients who were treated with maprotiline (16 of 25) showed improvement; only 28% of the identified patients who were electively not treated improved. Improvement occurred in only 18% of the control group. It appears that the diagnosis of depression is not ordinarily made in family medicine outpatient settings and that self-rating depression scales are useful diagnostic aids, whose regular use is indicated by the high prevalence of depression in general medical populations.

To deliver effective medical care to patients from all cultural backgrounds, family physicians need to be culturally sensitive and culturally competent. Our department implemented and evaluated a 3-year curriculum to increase residents' knowledge, skills, and attitudes in multicultural medicine. Our three curricular goals were to increase self-awareness about cultural influences on physicians, increase awareness about cultural influences on patients, and improve multicultural communication in clinical settings. Curricular objectives were arranged into five levels of cultural competence. Content was presented in didactic sessions, clinical settings, and community medicine projects.Residents did self-assessments at the beginning of the second year and at the end of the third year of the curriculum about their achievement and their level of cultural competence. Faculty's evaluations of residents' levels of cultural competence correlated significantly with the residents' final self-evaluations. Residents and faculty rated the overall curriculum as 4.26 on a 5-point scale (with 5 as the highest rating).Family practice residents' cultural knowledge, cross-cultural communication skills, and level of cultural competence increased significantly after participating in a multicultural curriculum.

BACKGROUND AND OBJECTIVES: Rural populations experience more adverse living circumstances than urban populations, but the evidence regarding the prevalence of mental health disorders in rural areas is contradictory. We examined the prevalence of depression in rural versus urban areas. METHODS: We performed a cross-sectional study using the 1999 National Health Interview Survey (NHIS). In face-to-face interviews, the NHIS administered the Composite International Diagnostic Interview Short Form (CIDI-SF) depression scale to a nationally representative sample of 30,801 adults, ages 18 and over. RESULTS: An estimated 2.6 million rural adults suffer from depression. The unadjusted prevalence of depression was significantly higher among rural than urban populations (6.1% versus 5.2% ). After adjusting for rural/urban population characteristics, however, the odds of depression did not differ by residence. Depression risk was higher among persons likely to be encountered in a primary care setting: those with fair or poor self-reported health, hypertension, with limitations in daily activities, or whose health status changed during the previous year. CONCLUSIONS: The prevalence of depression is slightly but significantly higher in residents of rural areas compared to urban areas, possibly due to differing population characteristics.

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PURPOSE: More than a decade ago the American Academy of Family Physicians, American Academy of Family Physicians Foundation, American Board of Family Medicine, Association of Departments of Family Medicine, Association of Family Practice Residency Directors, North American Primary Care Research Group, and Society of Teachers of Family Medicine came together in the Future of Family Medicine (FFM) to launch a series of strategic efforts to "renew the specialty to meet the needs of people and society," some of which bore important fruit. Family Medicine for America's Health was launched in 2013 to revisit the role of family medicine in view of these changes and to position family medicine with new strategic and communication plans to create better health, better health care, and lower cost for patients and communities (the Triple Aim). METHODS: Family Medicine for America's Health was preceded and guided by the development of a family physician role definition. A consulting group facilitated systematic strategic plan development over 9 months that included key informant interviews, formal stakeholder surveys, future scenario testing, a retreat for family medicine organizations and stakeholder representatives to review strategy options, further strategy refinement, and finally a formal strategic plan with draft tactics and design for an implementation plan. A second communications consulting group surveyed diverse stakeholders in coordination with strategic planning to develop a communication plan. The American College of Osteopathic Family Physicians joined the effort, and students, residents, and young physicians were included. RESULTS: The core strategies identified include working to ensure broad access to sustained, primary care relationships; accountability for increasing primary care value in terms of cost and quality; a commitment to helping reduce health care disparities; moving to comprehensive payment and away from fee-for-service; transformation of training; technology to support effective care; improving research underpinning primary care; and actively engaging patients, policy makers, and payers to develop an understanding of the value of primary care. The communications plan, called Health is Primary, will complement these strategies. Eight family medicine organizations have pledged nearly $20 million and committed representatives to a multiyear implementation team that will coordinate these plans in a much more systematic way than occurred with FFM. CONCLUSIONS: Family Medicine for America's Health is a new commitment by 8 family medicine organizations to strategically align work to improve practice models, payment, technology, workforce and education, and research to support the Triple Aim. It is also a humble invitation to patients and to clinical and policy partners to collaborate in making family medicine even more effective.

BACKGROUND: Recognizing fundamental flaws in the fragmented US health care systems and the potential of an integrative, generalist approach, the leadership of 7 national family medicine organizations initiated the Future of Family Medicine (FFM) project in 2002. The goal of the project was to develop a strategy to transform and renew the discipline of family medicine to meet the needs of patients in a changing health care environment. METHODS: A national research study was conducted by independent research firms. Interviews and focus groups identified key issues for diverse constituencies, including patients, payers, residents, students, family physicians, and other clinicians. Subsequently, interviews were conducted with nationally representative samples of 9 key constituencies. Based in part on these data, 5 task forces addressed key issues to meet the project goal. A Project Leadership Committee synthesized the task force reports into the report presented here. RESULTS: The project identified core values, a New Model of practice, and a process for development, research, education, partnership, and change with great potential to transform the ability of family medicine to improve the health and health care of the nation. The proposed New Model of practice has the following characteristics: a patient-centered team approach; elimination of barriers to access; advanced information systems, including an electronic health record; redesigned, more functional offices; a focus on quality and outcomes; and enhanced practice finance. A unified communications strategy will be developed to promote the New Model of family medicine to multiple audiences. The study concluded that the discipline needs to oversee the training of family physicians who are committed to excellence, steeped in the core values of the discipline, competent to provide family medicine's basket of services within the New Model, and capable of adapting to varying patient needs and changing care technologies. Family medicine education must continue to include training in maternity care, the care of hospitalized patients, community and population health, and culturally effective and proficient care. A comprehensive lifelong learning program for each family physician will support continuous personal, professional, and clinical practice assessment and improvement. Ultimately, systemwide changes will be needed to ensure high-quality health care for all Americans. Such changes include taking steps to ensure that every American has a personal medical home, promoting the use and reporting of quality measures to improve performance and service, advocating that every American have health care coverage for basic services and protection against extraordinary health care costs, advancing research that supports the clinical decision making of family physicians and other primary care clinicians, and developing reimbursement models to sustain family medicine and primary care practices. CONCLUSIONS: The leadership of US family medicine organizations is committed to a transformative process. In partnership with others, this process has the potential to integrate health care to improve the health of all Americans.

BACKGROUND: Over the last 10 years the number of medical students choosing family medicine as a career has steadily declined. Studies have demonstrated that career preference at the time that students begin medical school may be significantly associated with their ultimate career choice. We sought to identify the career preferences students have at entry to medical school and the factors related to family medicine as a first-choice career option. METHODS: A questionnaire was administered to students entering medical school programs at the time of entry at the University of Calgary (programs beginning in 2001 and 2002), University of British Columbia (2001 and 2002) and University of Alberta (2002). Students were asked to indicate their top 3 career choices and to rank the importance of 25 variables with respect to their career choice. Factor analysis was performed on the variables. Reliability of the factor scores was estimated using Cronbach's alpha coefficients; biserial correlations between the factors and career choice were also calculated. A logistic regression was performed using career choice (family v. other) as the criterion variable and the factors plus demographic characteristics as predictor variables. RESULTS: Of 583 students, 519 (89%) completed the questionnaire. Only 20% of the respondents identified family medicine as their first career option, and about half ranked family medicine in their top 3 choices. Factor analysis produced 5 factors (medical lifestyle, societal orientation, prestige, hospital orientation and varied scope of practice) that explained 52% of the variance in responses. The 5 factors demonstrated acceptable internal consistency and correlated in the expected direction with the choice of family medicine. Logistic regression revealed that students who identified family medicine as their first choice tended to be older, to be concerned about medical lifestyle and to have lived in smaller communities at the time of completing high school; they were also less likely to be hospital oriented. Moreover, students who chose family medicine were much more likely to demonstrate a societal orientation and to desire a varied scope of practice. INTERPRETATION: Several factors appear to drive students toward family medicine, most notably having a societal orientation and a desire for a varied scope of practice. If the factors that influence medical students to choose family medicine can be identified accurately, then it may be possible to use such a model to change medical school admission policies so that the number of students choosing to enter family medicine can be increased.

BACKGROUND: Recent decreases in the number of students entering family medicine has prompted reconsideration of what is known about the factors affecting specialty choice. METHODS: Thirty-six articles on family medicine specialty choice published since 1993 were reviewed and rated for quality. RESULTS: Rural background related positively and parents' socioeconomic status relates negatively to choice of family medicine. Career intentions at entry to medical school predict specialty choice. Students who believe primary care is important, have low income expectations, and do not plan a research career are more likely to choose family medicine. The school characteristic related to choice of family medicine is public ownership. Large programs to increase numbers entering primary care seem effective. Required family medicine time in clinical years is related to higher numbers selecting family medicine. Faculty role models serve both as positive and negative influences. Students rejecting family medicine are concerned about prestige, low income, and breadth of knowledge required. Students planning on a career in a disadvantaged or rural area are more likely to enter family medicine. CONCLUSIONS: Multiple factors are consistently shown to be related to the choice of the specialty of family medicine.

An invitational conference led by the World Organization of Family Doctors (Wonca) involving selected delegates from 34 countries was held in Kingston, Ontario, Canada, March 8 to 12, 2003. The conference theme was "Improving Health Globally: The Necessity of Family Medicine Research." Guiding conference discussions was the value that to improve health care worldwide, strong, evidence-based primary care is indispensable. Eight papers reviewed before the meeting formed the basic material from which the conference developed 9 recommendations. Wonca, as an international body of family medicine, was regarded as particularly suited to pursue these conference recommendations: 1. Research achievements in family medicine should be displayed to policy makers, health (insurance) authorities, and academic leaders in a systematic way. 2. In all countries, sentinel practice systems should be developed to provide surveillance reports on illness and diseases that have the greatest impact on the population's health and wellness in the community. 3. A clearinghouse should be organized to provide a central repository of knowledge about family medicine research expertise, training, and mentoring.4. National research institutes and university departments of family medicine with a research mission should be developed. 5. Practice-based research networks should be developed around the world.6. Family medicine research journals, conferences, and Web sites should be strengthened to disseminate research findings internationally, and their use coordinated. Improved representation of family medicine research journals in databases, such as Index Medicus, should be pursued.7. Funding of international collaborative research in family medicine should be facilitated.8. International ethical guidelines, with an international ethical review process, should be developed in particular for participatory (action) research, where researchers work in partnership with communities. 9. When implementing these recommendations, the specific needs and implications for developing countries should be addressed.The Wonca executive committee has reviewed these recommendations and the supporting rationale for each. They plan to follow the recommendations, but to do so will require the support and cooperation of many individuals, organizations, and national governments around the world.

The terms "family practice" and "family medicine" refer to different levels of activity and should be kept conceptually distinct. Using family practice and family medicine interchangeably blurs important differences between the two and encourages confusion between the issues of family medicine and those of primary care. This confusion, in turn, is contributing to a set of trends that threatens the continued development of family medicine as it is understood here. By developing family medicine as a discipline in its own right, the way is cleared for viewing the family as a vital system of medical concern and for putting the family into the center of medical-care delivery. The result would be a closer working relationship between family medicine and family practice than now exists.

Abstract Background Physician workforce projections by the Institute of Medicine require enhanced training in geriatrics for all primary care and subspecialty physicians. Defining essential geriatrics competencies for internal medicine and family medicine residents would improve training for primary care and subspecialty physicians. The objectives of this study were to (1) define essential geriatrics competencies common to internal medicine and family medicine residents that build on established national geriatrics competencies for medical students, are feasible within current residency programs, are assessable, and address the Accreditation Council for Graduate Medical Education competencies; and (2) involve key stakeholder organizations in their development and implementation. Methods Initial candidate competencies were defined through small group meetings and a survey of more than 100 experts, followed by detailed item review by 26 program directors and residency clinical educators from key professional organizations. Throughout, an 8-member working group made revisions to maintain consistency and compatibility among the competencies. Support and participation by key stakeholder organizations were secured throughout the project. Results The process identified 26 competencies in 7 domains: Medication Management; Cognitive, Affective, and Behavioral Health; Complex or Chronic Illness(es) in Older Adults; Palliative and End-of-Life Care; Hospital Patient Safety; Transitions of Care; and Ambulatory Care. The competencies map directly onto the medical student geriatric competencies and the 6 Accreditation Council for Graduate Medical Education Competencies. Conclusions Through a consensus-building process that included leadership and members of key stakeholder organizations, a concise set of essential geriatrics competencies for internal medicine and family medicine residencies has been developed. These competencies are well aligned with concerns for residency training raised in a recent Medicare Payment Advisory Commission report to Congress. Work is underway through stakeholder organizations to disseminate and assess the competencies among internal medicine and family medicine residency programs.