STFM - Sunday, May 1, Promoting Research Activity in Community Residency Programs The Residency Research Network of Texas * Presented by Sandra K. Burge, Ph.D. University of Texas Health Science Center San Antonio, TX *Funded by Health Resources & Services Administration (HRSA) And American Academy of Family Physicians Foundation

STFM - Sunday, May 1, The Residency Research Network of Texas

STFM - Sunday, May 1, Objectives Describe the need for increasing residency’s involvement in research Propose the RRNeT as one model for increasing involvement in research Mission Infrastructure Process Outcomes Discuss opportunities & challenges for research in residency programs

STFM - Sunday, May 1, Audience Are you… From community residency programs? From academic departments in universities? Members of research networks? Beginning researchers? Experienced researchers?

STFM - Sunday, May 1, A Challenge from FM Leadership: “All Family Physicians [should be involved in] the use and generation of new knowledge.” Dickinson WP et al. “Involving all Family Physicians and Family Medicine Faculty members in the Use and Generation of New Knowledge.” Family Medicine 2000; 32(7):

STFM - Sunday, May 1, Why is Research Important to Family Medicine? To improve patient care consistent with FM values & principles To document family physicians’ tacit knowledge about patient care To answer unanswered questions To address challenges in our health care system To strengthen FM’s voice in the community of Medicine

STFM - Sunday, May 1, If Not Us, Then Who? Do you want medical subspecialists to determine how to care for family medicine patients?

STFM - Sunday, May 1, Subjects in Traditional Medical Research 1000 in a community 800 have a symptom in one month 217 seek care visit PC provider 8 Them Us

STFM - Sunday, May 1, Who Does FM Research Now? Research inhabits a tiny little corner of the FM world – in academic centers Only 8.5% STFM members published a journal article in 1999 (Weiss) Among 869 family medicine research authors in , only 10% were from community residency programs (Pathman) However, 83% family medicine residents were in community programs (2003-4)

STFM - Sunday, May 1, Barriers to Research Many faculty in community programs have little time to do research; have little access to research resources; have little training in research; have few researcher peers Most programs do not have the funding to build research programs or hire research faculty & staff

STFM - Sunday, May 1, One Option: Residency-based Research Networks

STFM - Sunday, May 1, RRNeT – The Beginning In the middle 1990’s AAFP - small grants to develop research skills in community residency programs PBRN Directors Included residency programs in their research networks

STFM - Sunday, May 1, RRNeT – The Beginning HRSA Grant Deadline, 1996 “Academic Administrative Units” HRSA funding received 1997 – 2000 (“Academic Admin Units”) 2000 – 2003 (“Academic Admin Units”) 2003 – 2006 (“Faculty Development”)

STFM - Sunday, May 1, RRNeT Mission: To examine health issues relevant to family medicine patients in Texas To increase community program faculty and residents’ skills and involvement in research

STFM - Sunday, May 1, Infrastructure

STFM - Sunday, May 1, Infrastructure - RRNeST In 1997, Five FM Residency Programs 1. San Antonio, UTHSC 2. San Antonio, Christus Santa Rosa Hospital 3. Corpus Christi, Christus Memorial Hospital 4. Harlingen, Valley Baptist Medical Center 5. McAllen, McAllen Medical Center And One Private Practice 6. Laredo, Laredo Medical Group

STFM - Sunday, May 1, Infrastructure In 2004, more Texas Programs joined: 1. Austin – Brackenridge Hospital 2. Fort Worth – John Peter Smith Hospital 3. Dallas - Charlton Methodist Hospital And, the Laredo practice moved to STARNet

STFM - Sunday, May 1, Eight Residency Programs LocationRepresentative# Patient Visits/ Year # MD Faculty # FM Residents AustinDavid Weigle, PhD20, Corpus ChristiJohn Whitham MD Richard Barry MD 37, DallasAlishia Ferguson,MA14, Fort WorthRichard Young, MD38, HarlingenDarryl White, MD20, McAllenJuan Trevino, MD27, San Antonio – SREllen Bajorek, PhD17, San Antonio - UTSandra Burge, PhD55, TOTAL 229,

STFM - Sunday, May 1, Patient Populations Location #Patient Visits Per Year % African American % Latino% Anglo Austin20,00030% 40% Corpus Christi37,0004%75%15% Dallas14,40040%30% Fort Worth38,00032% Harlingen20,0005%72%19% McAllen27,3001%93%6% San Antonio – SR17,0005%73%17% San Antonio – UT55,5009%77%14% TOTAL229,20014%63%20%

STFM - Sunday, May 1, Infrastructure Funds for: 30% Network Director (Ph.D. Researcher) 50% Network Coordinator Travel between sites Travel to national meetings Regular communication & meetings Funds for data collection efforts Software (SPSS for everyone!) Also use Other research faculty & biostatistician time

STFM - Sunday, May 1, Process

STFM - Sunday, May 1, RRNeT Process Membership Program Director agrees to participation Program Director selects a faculty representative to the network Research Director Program Director Behavioral Science Director Residents are encouraged to participate.

STFM - Sunday, May 1, RRNeT Process Training Network Director & other UTHSCSA faculty visit each program and offer Research Methods Workshops to faculty & residents Ongoing training of residents, staff, & faculty becomes the responsibility of the network representative. UTHSCSA faculty are available for further training, if desired.

STFM - Sunday, May 1, RRNeT Process Communication Network representatives meet regularly Conference Call every two months Two face-to-face meetings per year List-serve Website – (updating now) Fax, postal service, telephone, Whatever works! Everyone has a different preference!

STFM - Sunday, May 1, RRNeT Process How a project begins: Research ideas come from the community programs – residents or faculty Time is allotted at face-to-face meetings to brainstorm new project ideas The network members prioritize ideas The members brainstorm a feasible protocol

STFM - Sunday, May 1, RRNeT Process How a project develops: We match the idea with a university “content expert.” One person writes up a protocol draft. RRNeT members critique & refine the protocol during regular meetings. Key author revises the protocol. Network director & coordinator begin the IRB approval process.

STFM - Sunday, May 1, RRNeT Process Data collection RRNeT representatives oversee data collection at their programs Data is forwarded to UTHSCSA Coordinator creates one large database

STFM - Sunday, May 1, RRNeT Process Quantitative Data Analysis Done at UTHSCSA Network Director, or “Content Expert,” With assistance from local biostatisticians Qualitative Data Analysis Involves any member with time & interest Meet by conference call

STFM - Sunday, May 1, RRNeT Process Dissemination, Step 1. Data tables are drafted Data are presented to all network members Director asks physicians to “interpret” the findings, asking “How would this influence your practice?” Dissemination, Step 2. Network reps take data tables back to their program for more input re: data interpretation

STFM - Sunday, May 1, RRNeT Process Dissemination, Step 3. Annually, RRNeT submits abstracts to AAFP STFM NAPCRG Network representatives are encouraged to present or co-present the papers Director can be available as a co-presenter statistical analysis

STFM - Sunday, May 1, RRNeT Process Dissemination, Step 4. Journal articles Director seeks volunteers for writing Lead author varies; authorship sequence decided by effort All network reps are included as co-authors because of their involvement in conceiving the question & protocol, collecting data, interpreting results, and presenting papers. Some journals limit # authors

STFM - Sunday, May 1, Outcomes

STFM - Sunday, May 1, RRNeT Outcomes Projects Completed Alternative Medicine Use Quality of Care for Diabetes A Brief Intervention for Medication Adherence Adolescent Preventive Services Firearm Safety

STFM - Sunday, May 1, RRNeT Outcomes Topics under consideration Pedometers to promote physical activity Nutrition, esp. “5-A-Day” Physicians’ use of sample closet medicines Patients’ use of antibiotics from Mexico Physicians’ attitudes toward chronic pain management

STFM - Sunday, May 1, RRNeT Outcomes 7 National Presentations (peer reviewed): AAFP 2000 a, 2001 a, 2004 a STFM 2000 a, 2001 a, 2003 a, 2004 b 5 International Presentations (peer reviewed) WONCA 2002 a NAPCRG 1999 b, 2000 b, 2002 b, 2004 b 1 Regional Presentation (peer reviewed) TAFP 1998 a a.Presented or co-presented by Community Program Faculty b.Presented by UTHSCSA faculty

STFM - Sunday, May 1, RRNeT Outcomes 4 Research Awards 1999 TAFP Physician’s Research Award Cigarroa L. “Use of Complementary and Alternative Medicines Among Family Practice patients in South Texas” 2000 AAFP Second-Place Award for Research Albright T. “Predictors of Self-Care for Diabetes” 2001 AAFP Second-Place Award for Research Albright T. “Improving Firearm Storage Habits: The Impact of Brief Office Counseling by Family Physicians.” 2003 STFM Distinguished Paper Award White & Burge “Correlates of Medication Knowledge and Compliance”

STFM - Sunday, May 1, RRNeT Outcomes 2 Published Abstracts McCutchon T, Burge SK, et al. “Use of Complementary and Alternative Medicines Among Family Practice patients in South Texas: An RRNeST Study.” Family Medicine 2000, (July/Aug). Albright T, Parchman M, et al. Family Support Is Strongest Indicator of Self-Care Compliance: “Conference Highlights from the Annual Scientific Assembly of AAFP.” American Family Physician 2000 (Dec 15).

STFM - Sunday, May 1, RRNeT Outcomes 5 Journal Articles (peer reviewed) Burge SK, White D, Bajorek E, et al. Correlates of Medication Knowledge and Compliance. Family Medicine, in press. Albright T, Burge SK. Improving firearm storage habits… JABFP 2003; 16: Burge SK, Albright T, RRNeST Investigators. Complementary and alternative medicine use… AJPH 2002, 92(10): Parchman ML, Burge SK, RRNeST Investigators. Continuity and quality of care in type 2 diabetes. Journal of Family Practice 2000; 51(7): McCutchon TA, Parchman M, Burge SK, RRNeST Investigators. Predictors of Self Care Behavior in Adults with Type 2 Diabetes. Family Medicine 2001; 33(5):

STFM - Sunday, May 1, Benefits to Networking Residency Programs

STFM - Sunday, May 1, Benefits to Community Programs Addresses RRC requirements for research “Each program must encourage and provide opportunities for residents to participate in research or other scholarly activities.” “The faculty as a whole must demonstrate broad involvement in scholarly activity” Active curricula promoting a spirit of inquiry Active participation in scientific societies Participation in peer-reviewed research Provision of guidance to residents

STFM - Sunday, May 1, Benefits to Community Programs Increases faculty research experience Increases residents’ exposure to research Creates a peer group of researchers Provides links to research-savvy faculty Provides opportunities to present & publish Provides national exposure for program

STFM - Sunday, May 1, Benefits to University Faculty Provides access to large & unique patient populations Provides practice-savvy and teaching- savvy collaborators for “reality testing” Provides opportunities for presentation & publication – Increasing chances for promotion & tenure Increasing chances for grant funding

STFM - Sunday, May 1, Benefits to the Discipline Contributes new knowledge to discipline Addresses regional health care issues Provides access to unique patient populations Under-insured patients; Minorities Presents unique clinical questions Expands the Family Medicine Research Culture Increases research sophistication in faculty, residents, and practitioners

STFM - Sunday, May 1, Networking Residency Programs: Challenges

STFM - Sunday, May 1, Challenge: Distance 550 miles

STFM - Sunday, May 1, Challenges Limited faculty time Limited support staff time Limited funding We have broad interests, not a Institute- friendly research focus State Academy has its own network to support IRB!! HIPAA!!

STFM - Sunday, May 1, Adaptations to Challenges Representatives’ time & distance fewer face-to-face meetings; more end-of-day conference calls Program staff time medical student research internship under development Funding appealing to “content experts”; writing grants; developing simple (inexpensive) protocols IRB Perseverance; endurance; swear words when indicated

STFM - Sunday, May 1, Opportunity! AAFP National Research Network is interested in recruiting residency programs Membership requires agreement from Program Director Research Director One Staff as Research Coordinator

STFM - Sunday, May 1, What Are Your Experiences? How does your program promote research skills and involvement? With faculty and residents What benefits do you see? What are the challenges you face? How do you address your challenges?

STFM - Sunday, May 1, Thank You…