Do Registered Reports Make Scientific Findings More Believable to the Public?

Registered reports are an important initiative to improve the methodological rigor and transparency of scientific studies. One possible benefit of registered reports is that they may increase public acceptance of controversial research findings. We test this question by providing participants in a large US-based sample (n = 1,500) with descriptions of the key features of registered reports and the standard peer-review process, and then eliciting credibility judgments for various scientific results. We do not find evidence that participants view findings from registered reports as more credible than findings conducted under a standard (non-registered) report. This was true for both plausible and implausible study findings. Our results help clarify public attitudes and beliefs about scientific findings in light of recent methodological developments.

Development and evaluation of a primary care antimicrobial stewardship program (PC-ASP) in Toronto, Ontario, Canada

BACKGROUND

Effective community-based antimicrobial stewardship programs (ASPs) are needed because 90% of antimicrobials are prescribed in the community. A primary care ASP (PC-ASP) was evaluated for its effectiveness in lowering antibiotic prescriptions for six common infections.

METHODS

A multi-faceted educational program was assessed using a before-and-after design in four primary care clinics from 2015 through 2017. The primary outcome was the difference between control and intervention clinics in total antibiotic prescriptions for six common infections before and after the intervention. Secondary outcomes included changes in condition-specific antibiotic use, delayed antibiotic prescriptions, prescriptions exceeding 7 days duration, use of recommended antibiotics, and emergency department visits or hospitalizations within 30 days. Multi-method models adjusting for demographics, case mix, and clustering by physician were used to estimate treatment effects.

RESULTS

Total antibiotic prescriptions in control and intervention clinics did not differ (difference in differences = 1.7%; 95% CI -12.5% to 15.9%), nor did use of delayed prescriptions (-5.2%; 95% CI -24.2% to 13.8%). Prescriptions for longer than 7 days were significantly reduced (-21.3%; 95% CI -42.5% to -0.1%). However, only 781 of 1,777 encounters (44.0%) involved providers who completed the ASP education. Where providers completed the education, delayed prescriptions increased 17.7% (p = 0.06), and prescriptions exceeding 7 days duration declined (-27%; 95% CI -48.3% to -5.6%). Subsequent emergency department visits and hospitalizations did not increase.

CONCLUSIONS

PC-ASP effectiveness on antibiotic use was variable. Shorter prescription durations and increased use of delayed prescriptions were adopted by engaged primary care providers.

Barriers and facilitators to the uptake of an antimicrobial stewardship program in primary care: A qualitative study

The overuse of antimicrobials in primary care can be linked to an increased risk of antimicrobial-resistant bacteria for individual patients. Although there are promising signs of the benefits associated with Antimicrobial Stewardship Programs (ASPs) in hospitals and long-term care settings, there is limited knowledge in primary care settings and how to implement ASPs in these settings is unclear. In this context, a qualitative study was undertaken to explore the perceptions of primary care prescribers of the usefulness, feasibility, and experiences associated with the implementation of a pilot community-focused ASP intervention in three primary care clinics. Qualitative interviews were conducted with primary care clinicians, including local ASP champions, prescribers, and other primary health care team members, while they participated in an ASP initiative within one of three primary care clinics. An iterative conventional content analyses approach was used to analyze the transcribed interviews. Themes emerged around the key enablers and barriers associated with ASP implementation. Study findings point to key insights relevant to the scalability of community ASP activities with primary care providers.

The state-of-play in physician health systems leadership research

Purpose

This paper aims to review a decade of evidence on physician participation in health system leadership with the view to better understand the current state of scholarship on physician leadership activity in health systems. This includes examining the available evidence on both physicians’ experiences of health systems leadership (HSL) and the impact of physician leadership on health system reform.

Design/methodology/approach

A state-of-the-art review of studies (between 2007 and 2017); 51 papers were identified, analyzed thematically and synthesized narratively.

Findings

Six main themes were identified in the literature as follows: (De)motivation for leadership, leadership readiness and career development, work demands and rewards, identity matters: acceptance of self (and other) as leader, leadership processes and relationships across health systems and leadership in relation to health system outcomes. There were seemingly contradictory findings across some studies, pointing to the influence of regional and cultural contextual variation on leadership practices as well entrenched paradoxical tensions in health system organizations.

Research limitations/implications

Future research should examine the influence of varying structural and psychological empowerment on physician leadership practices. Empirical attention to paradoxical tensions (e.g. between empowerment and control) in HSL is needed, with specific attention to questions on how such tensions influence leaders’ decision-making about system reform.

Originality/value

This review provides a broad synthesis of diverse papers about physician participation in health system leadership. Thus, it offers a comprehensive empirical synthesis of contemporary concerns and identifies important avenues for future research.

Civic honesty around the globe

Civic honesty is essential to social capital and economic development but is often in conflict with material self-interest. We examine the trade-off between honesty and self-interest using field experiments in 355 cities spanning 40 countries around the globe. In these experiments, we turned in more than 17,000 lost wallets containing varying amounts of money at public and private institutions and measured whether recipients contacted the owners to return the wallets. In virtually all countries, citizens were more likely to return wallets that contained more money. Neither nonexperts nor professional economists were able to predict this result. Additional data suggest that our main findings can be explained by a combination of altruistic concerns and an aversion to viewing oneself as a thief, both of which increase with the material benefits of dishonesty.

Is postgraduate leadership education a match for the wicked problems of health systems leadership? A critical systematic review

PURPOSE

There have been a growing number of leadership education programs for physicians. However, debates about the value and efficacy of leadership education in medicine persist, and there are calls for systematic and critical perspectives on medical leadership development. Here, we review evidence on postgraduate leadership education and discuss findings in relation to contemporary evidence on leadership education and practice.

METHOD

We searched multiple databases for papers on postgraduate leadership development programs, published in English between 2007 and 2017. We identified 4,691 papers; 31 papers met the full inclusion criteria. Data regarding curricular content and design, learner demographics, instructional methods, and learning outcomes were abstracted and synthesized.

RESULTS

There was modest evidence for effectiveness of programs in influencing knowledge and skills gains in select domains. However, the conceptual underpinnings of the 'leadership' training delivered were often unclear. Contemporary theory and evidence on leadership practice was not widely incorporated in program design. Programs were almost exclusively uni-professional, focused on discrete skill development, and did not address systems-level leadership issues. Broader leadership capacity building strategies were underutilized. A new wave of longitudinal, integrated clinical and leadership programming is observed.

CONCLUSIONS

Our findings raise questions about persistent preparation-practice gaps in leadership education in medicine. Leadership education needs to evolve to incorporate broader collective capacity building, as well as evidence-informed strategies for leadership development. Barriers to educational reform need to be identified and addressed as educators work to re-orientate education programs to better prepare budding physician leaders for the challenges of health system leadership.

What influences success in family medicine maternity care education programs? Qualitative exploration

OBJECTIVE

To ascertain how program leaders in family medicine characterize success in family medicine maternity care education and determine which factors influence the success of training programs.

DESIGN

Qualitative research using semistructured telephone interviews.

SETTING

Purposive sample of 6 family medicine programs from 5 Canadian provinces.

PARTICIPANTS

Eighteen departmental leaders and program directors.

METHODS

Semistructured telephone interviews were conducted with program leaders in family medicine maternity care. Departmental leaders identified maternity care programs deemed to be "successful." Interviews were audiorecorded and transcribed verbatim. Team members conducted thematic analysis.

MAIN FINDINGS

Participants considered their education programs to be successful in family medicine maternity care if residents achieved competency in intrapartum care, if graduates planned to include intrapartum care in their practices, and if their education programs were able to recruit and retain family medicine maternity care faculty. Five key factors were deemed to be critical to a program's success in family medicine maternity care: adequate clinical exposure, the presence of strong family medicine role models, a family medicine-friendly hospital environment, support for the education program from multiple sources, and a dedicated and supportive community of family medicine maternity care providers.

CONCLUSION

Training programs wishing to achieve greater success in family medicine maternity care education should employ a multifaceted strategy that considers all 5 of the interdependent factors uncovered in our research. By paying particular attention to the informal processes that connect these factors, program leaders can preserve the possibility that family medicine residents will graduate with the competence and confidence to practise full-scope maternity care.

Thinking More or Feeling Less? Explaining the Foreign-Language Effect on Moral Judgment

Would you kill one person to save five? People are more willing to accept such utilitarian action when using a foreign language than when using their native language. In six experiments, we investigated why foreign-language use affects moral choice in this way. On the one hand, the difficulty of using a foreign language might slow people down and increase deliberation, amplifying utilitarian considerations of maximizing welfare. On the other hand, use of a foreign language might stunt emotional processing, attenuating considerations of deontological rules, such as the prohibition against killing. Using a process-dissociation technique, we found that foreign-language use decreases deontological responding but does not increase utilitarian responding. This suggests that using a foreign language affects moral choice not through increased deliberation but by blunting emotional reactions associated with the violation of deontological rules.

Data from a pre-publication independent replication initiative examining ten moral judgement effects

We present the data from a crowdsourced project seeking to replicate findings in independent laboratories before (rather than after) they are published. In this Pre-Publication Independent Replication (PPIR) initiative, 25 research groups attempted to replicate 10 moral judgment effects from a single laboratory's research pipeline of unpublished findings. The 10 effects were investigated using online/lab surveys containing psychological manipulations (vignettes) followed by questionnaires. Results revealed a mix of reliable, unreliable, and culturally moderated findings. Unlike any previous replication project, this dataset includes the data from not only the replications but also from the original studies, creating a unique corpus that researchers can use to better understand reproducibility and irreproducibility in science.

Closing the circle of care: implementation of a web-based communication tool to improve emergency department discharge communication with family physicians

OBJECTIVE

Postdischarge emergency department (ED) communication with family physicians is often suboptimal and negatively impacts patient care. We designed and piloted an online notification system that electronically alerts family physicians of patient ED visits and provides access to visitspecific laboratory and diagnostic information.

METHODS

Nine (of 10 invited) high-referring family physicians participated in this single ED pilot. A prepilot chart audit (30 patients from each family physician) determined the baseline rate of paper-based record transmission. A webbased communication portal was designed and piloted by the nine family physicians over 1 year. Participants provided usability feedback via focus groups and written surveys.

RESULTS

Review of 270 patient charts in the prepilot phase revealed a 13% baseline rate of handwritten chart and a 44% rate of any information transfer between the ED and family physician offices following discharge. During the pilot, participant family physicians accrued 880 patient visits. Seven and two family physicians accessed online records for 74% and 12% of visits, respectively, an overall 60.7% of visits, corresponding to an overall absolute increase in receipt of patient ED visit information of 17%. The postpilot survey found that 100% of family physicians reported that they were ''often'' or ''always'' aware of patient ED visits, used the portal ''always'' or ''regularly'' to access patients' health records online, and felt that the web portal contributed to improved actual and perceived continuity of patient care.

CONCLUSION

Introduction of a web-based ED visit communication tool improved ED-family physician communication. The impact of this system on improved continuity of care, timeliness of follow-up, and reduced duplication of investigations and referrals requires additional study.

Nudging physician prescription decisions by partitioning the order set: results of a vignette-based study

BACKGROUND

Healthcare professionals are rapidly adopting electronic health records (EHRs). Within EHRs, seemingly innocuous menu design configurations can influence provider decisions for better or worse.

OBJECTIVE

The purpose of this study was to examine whether the grouping of menu items systematically affects prescribing practices among primary care providers.

PARTICIPANTS

We surveyed 166 primary care providers in a research network of practices in the greater Chicago area, of whom 84 responded (51% response rate). Respondents and non-respondents were similar on all observable dimensions except that respondents were more likely to work in an academic setting.

DESIGN

The questionnaire consisted of seven clinical vignettes. Each vignette described typical signs and symptoms for acute respiratory infections, and providers chose treatments from a menu of options. For each vignette, providers were randomly assigned to one of two menu partitions. For antibiotic-inappropriate vignettes, the treatment menu either listed over-the-counter (OTC) medications individually while grouping prescriptions together, or displayed the reverse partition. For antibiotic-appropriate vignettes, the treatment menu either listed narrow-spectrum antibiotics individually while grouping broad-spectrum antibiotics, or displayed the reverse partition.

MAIN MEASURES

The main outcome was provider treatment choice. For antibiotic-inappropriate vignettes, we categorized responses as prescription drugs or OTC-only options. For antibiotic-appropriate vignettes, we categorized responses as broad- or narrow-spectrum antibiotics.

KEY RESULTS

Across vignettes, there was an 11.5 percentage point reduction in choosing aggressive treatment options (e.g., broad-spectrum antibiotics) when aggressive options were grouped compared to when those same options were listed individually (95% CI: 2.9 to 20.1%; p = .008).

CONCLUSIONS

Provider treatment choice appears to be influenced by the grouping of menu options, suggesting that the layout of EHR order sets is not an arbitrary exercise. The careful crafting of EHR order sets can serve as an important opportunity to improve patient care without constraining physicians' ability to prescribe what they believe is best for their patients.

CRM1 inhibition induces tumor cell cytotoxicity and impairs osteoclastogenesis in multiple myeloma: molecular mechanisms and therapeutic implications

The key nuclear export protein CRM1/XPO1 may represent a promising novel therapeutic target in human multiple myeloma (MM). Here we showed that chromosome region maintenance 1 (CRM1) is highly expressed in patients with MM, plasma cell leukemia cells and increased in patient cells resistant to bortezomib treatment. CRM1 expression also correlates with increased lytic bone and shorter survival. Importantly, CRM1 knockdown inhibits MM cell viability. Novel, oral, irreversible selective inhibitors of nuclear export (SINEs) targeting CRM1 (KPT-185, KPT-330) induce cytotoxicity against MM cells (ED50<200 nM), alone and cocultured with bone marrow stromal cells (BMSCs) or osteoclasts (OC). SINEs trigger nuclear accumulation of multiple CRM1 cargo tumor suppressor proteins followed by growth arrest and apoptosis in MM cells. They further block c-myc, Mcl-1, and nuclear factor κB (NF-κB) activity. SINEs induce proteasome-dependent CRM1 protein degradation; concurrently, they upregulate CRM1, p53-targeted, apoptosis-related, anti-inflammatory and stress-related gene transcripts in MM cells. In SCID mice with diffuse human MM bone lesions, SINEs show strong anti-MM activity, inhibit MM-induced bone lysis and prolong survival. Moreover, SINEs directly impair osteoclastogenesis and bone resorption via blockade of RANKL-induced NF-κB and NFATc1, with minimal impact on osteoblasts and BMSCs. These results support clinical development of SINE CRM1 antagonists to improve patient outcome in MM.

When it takes a bad person to do the right thing

Three studies demonstrate that morally praiseworthy behavior can signal negative information about an agent's character. In particular, consequentialist decisions such as sacrificing one life to save an even greater number of lives can lead to unfavorable character evaluations, even when they are viewed as the preferred course of action. In Study 1, throwing a dying man overboard to prevent a lifeboat from sinking was perceived as the morally correct course of action, but led to negative aspersions about the motivations and personal character of individuals who carried out such an act. In Studies 2 and 3, a hospital administrator who decided not to fund an expensive operation to save a child (instead buying needed hospital equipment) was seen as making a pragmatic and morally praiseworthy decision, but also as deficient in empathy and moral character.

Redesigning family medicine residency in Canada: the triple C curriculum

BACKGROUND AND OBJECTIVES

Despite a record of excellence, Canadian family medicine residency programs must respond to the changing face of health care and the needs of the population. A working group was established by the College of Family Physicians of Canada to review the current curriculum and make recommendations for change.

METHODS

Literature reviews of current evidence regarding strategies in postgraduate medical education were carried out, and recent developments in medical education internationally were studied. After recommendations for curriculum change were drafted, workshops, presentations, and peer consultations were conducted over a 4-year period to test ideas and obtain stakeholder feedback.

RESULTS

The core recommendation of the working group is: Residency programs in family medicine are to establish a competency-based curriculum that is comprehensive, focused on continuity, and centered in family medicine--The Triple C Competency-based Curriculum. The working group developed a new framework for family medicine competency in Canada, CanMEDS-FM, to support the transition.

CONCLUSIONS

The Triple C Competency-based Curriculum was developed to redesign Canadian family medicine residencies based on a solid rationale. Recommendations for curricular change, as well as the competency framework, CanMEDS-FM, have been accepted enthusiastically by stakeholders. Implementation and evaluation phases are underway.

A comparative analysis of the perceived continuing medical education needs of a cohort of rural and urban Canadian family physicians

OBJECTIVE

To assess the perceived continuing medical education (CME) needs of a cohort of Canadian family physicians.

METHODS

We distributed a questionnaire survey to Canadian family physicians who became Certificant members of the College of Family Physicians in 2001 and practised outside the province of Quebec. Main outcome measures were self-reported CME needs, professional development needs and preferences for CME delivery methods.

RESULTS

We distributed 482 surveys and 197 questionnaires were returned for a response rate of 40.9%. Significant differences between rural and urban respondents' self-reported CME needs were found in the clinical areas of dermatology, endocrinology, emergency medicine, musculoskeletal, ophthalmology, otolaryngology, psychiatry and urology. Generally, a greater proportion of rural respondents reported significantly higher CME needs in emergency medicine. Urban respondents reported a significant preference for consulting colleagues as a method of CME, while rural respondents reported a significant preference for videoconferencing.

CONCLUSION

Self-reported CME needs and preferences for CME delivery methods differ on the basis of region of practice and size of the community in which family physicians' practise.

Breast self-examination: resistance to change

OBJECTIVE

To investigate whether Canadian family practitioners routinely teach breast self-examination (BSE) after publication of the 2001 Canadian Preventive Health Task Force guideline advising them to exclude teaching BSE from periodic health examinations.

DESIGN

Self-administered cross-sectional mailed survey.

SETTING

Canada.

PARTICIPANTS

A random sample of English-speaking general practitioners and physicians certified by the College of Family Physicians of Canada.

MAIN OUTCOME MEASURES

Current and past BSE practices and opinions on the value of BSE.

RESULTS

Response rate was 47.4%. Most respondents (88%) were aware of the new recommendations, yet only 16% had changed their usual practice of routinely teaching BSE. Most physicians agreed that before the recommendation they almost always taught BSE (74.3%). Only 9.5% agreed that physicians should follow the recommendation and not routinely teach BSE. A few also agreed that they now spend less time discussing BSE (25.7%) and that the recommendation has influenced them to stop teaching (12.4%) and encouraging (12.9%) women to practise BSE. Physicians who had changed their BSE practices were less likely to agree that BSE increases early detection of breast cancer and more likely to agree that BSE increases benign breast biopsies. They were also more likely to agree that screening mammography in women older than 50 decreases mortality from breast cancer.

CONCLUSION

This survey, which assessed routine teaching of BSE, revealed poor adherence by Canadian family physicians to a well publicized evidence-based guideline update. Resistance to change could in part be attributed to a lack of knowledge of the supporting evidence, a lack of confidence in the evidence to date, and personal experiences with patients within their practices.

Structured assessment of minor surgical skills (SAMSS) for family medicine residents

PURPOSE

To develop a valid and reliable examination to assess the technical proficiency of family medicine residents' performance of minor surgical office procedures.

METHOD

A multi-station OSCE-style examination using bench-model simulations of minor surgical procedures was developed. Participants were a randomly selected group of 33 family medicine residents (PGY-1 = 16, PGY-2 = 17) and 14 senior surgical residents who functioned as a validation group. Examiners were qualified surgeons and family physicians who used both checklists and global rating scales to score the participants' performances.

RESULTS

When family medicine residents were evaluated by family physicians, interstation reliabilities were .29 for checklists and .42 for global ratings. When family medicine residents were evaluated by surgeons, the reliabilities were .53 for checklists and .75 for global ratings. Interrater reliability, measured as a correlation for total examination scores, was .97. Mean scores on the examination were 60%, 64%, and 87% for PGY-1 family medicine, PGY-2 family medicine, and surgery residents, respectively. The difference in scores between family medicine and surgery residents was significant (p < .001), providing evidence of construct validity.

CONCLUSION

A new examination developed for assessing family medicine residents' skills with minor surgical office procedures is reliable and has evidence for construct validity. The examination has low reliability when family physicians serve as examiners, but moderate reliability when surgeons are the evaluators.

A clinical score to reduce unnecessary antibiotic use in patients with sore throat

OBJECTIVE

To validate a score based on clinical symptoms and signs for the identification of group A Streptococcus (GAS) infection in general practice patients with score throat.

DESIGN

A single throat swab was used as the gold standard for diagnosing GAS infection. Clinical information was recorded by experienced family physicians on standardized encounter forms. Score criteria were identified by means of logistic regression modelling of data from patients enrolled in the first half of the study. The score was then validated among the remaining patients.

SETTING

University-affiliated family medicine centre in Toronto.

PATIENTS

A total of 521 patients aged 3 to 76 years presenting with a new upper respiratory tract infection from December 1995 to February 1997.

OUTCOME MEASURES

Sensitivity, specificity and likelihood ratios for identification of GAS infection with the score approach compared with throat culture. Proportion of patients prescribed antibiotics, throat culture use, and sensitivity and specificity with usual physician care and with score-based recommendations were compared.

RESULTS

A score was developed ranging in value from 0 to 4. The sensitivity of the score for identifying GAS infection was 83.1%, compared with 69.4% for usual physician care (p = 0.06); the specificity values of the 2 approaches were similar. Among patients aged 3 to 14 years, the sensitivity of the score approach was higher than that of usual physician care (96.9% v. 70.6%) (p < 0.05). The proportion of patients receiving initial antibiotic prescriptions would have been reduced 48% by following score-based recommendations compared with observed physician prescribing (p < 0.001), without any increase in throat culture use.

CONCLUSIONS

An age-appropriate sore throat score identified GAS infection in children and adults with sore throat better than usual care by family physicians, with significant reductions in unnecessary prescribing of antibiotics. A randomized trial comparing the 2 approaches is recommended to determine the ability of the score approach to reduce unnecessary prescribing of antibiotics during routine clinical encounters.

Model for assessing psychosocial problems

The Model for the Assessment of Psychosocial Problems (MAPP) can help family medicine residents effectively assess patients with psychosocial problems. Following a patient-centred clinical method, MAPP provides a guide to exploring problems and an approach that allows residents and patients jointly to define problems and decide upon management. Emphasis is placed on clarifying patients' expectations of physicians.

Intraoperative hand retractor

A technique is described that greatly reduces the problems inherent in obtaining clear radiographs of the fingers. The method is simple, inexpensive, and readily available for use in the operating room. Additionally, it allows the surgeon to leave the operative field and stand behind a lead shield while radiographs are taken.

Family Orientation in Family Medicine Training: A survey of Canadian programs

Teaching about the family has become an important part of the family medicine curriculum. The family orientation index, a 39-item questionnaire, was designed to evaluate the family orientation of services and care provided as well as the teaching and research. The questionnaire was distributed to 55 program directors at 16 Canadian universities. The response rate was 84%. The results indicate that the family orientation of services is less than optimal.

Structural relationships of the major glycoproteins from human alveolar proteinosis surfactant

Alveolar proteinosis is a disease characterized by accumulation of proteinaceous material in the alveolar space of the lung. Two major collagenase-sensitive polypeptides, alveolar proteinosis peptides of 34 kDa kilodaltons (APP-34) and of 62 kDa (APP-62), were isolated from bronchioalveolar lavage of patients with alveolar proteinosis. These proteins co-purified during fast-performance liquid chromatography (FPLC) chromatofocusing and were separated from each other by electroelution following SDS-polyacrylamide gel electrophoresis. Immunoblot analysis of these proteins demonstrated that both shared antigenic sites with the normal human surfactant-associated protein of Mr 34,000 (SAP-34) using both polyclonal and monoclonal antibodies generated against SAP-34. Removal of asparagine-linked oligosaccharides from the 34 kDa and 62 kDa alveolar proteinosis proteins with endoglycosidase F resulted in polypeptides of 28 kDa from APP-34 and 56 kDa from APP-62. Amino acid analysis and tryptic peptide maps of the electroeluted APP-34 and APP-62 proteins were essentially identical and similar to that previously reported for human SAP-34, supporting the likely relationship of APP-34 and APP-62 as monomer and dimer of the normal SAP-34. APP-34 and APP-62 were both sensitive to bacterial collagenase, yielding collagenase-resistant fragments of 21 kDa, similar in migration and amino acid composition to the fragment generated by collagenase digestion of normal human SAP-34. High molecular weight aggregates of APP-34 and APP-62 were the result of sulfhydryl-dependent and non-sulfhydryl-dependent cross-linking. A domain in the C-terminal non-collagenous portion of the molecules which forms sulfhydryl-dependent oligomers was identified. The two major polypeptides accumulating in the airway of patients with alveolar proteinosis are monomeric (34 kDa) and dimeric (62 kDa) forms of the major surfactant-associated glycoprotein, SAP-34.

What do family practice residents do in prevention and counselling?

A study was undertaken to measure what family practice residents do in prevention and counselling during routine check-ups on adults. A series of Health Monitoring and Promotion (HMP) measures were used to assess the content of the check-up. The residents were given a sheet of guidelines in an attempt to augment performance of the HMP measures. Using one-way glass, 353 patient encounters were observed. Analysis of 171 encounters before and 182 encounters after the introduction of the guidelines showed that the guidelines positively influenced the residents' behavior by increasing the number of HMP measures performed. Preventive items of a physical nature were carried out 61.2% of the time before the introduction of the guidelines and 69.7% after, with more pronounced improvement when dealing with the 18-39 age group and among men. Similar changes occurred on historical items of a preventive type, but history-taking from women was more positively influenced. Preventive counselling was carried out 20% of the time and was uninfluenced by the guidelines. There was a high level of breast and testicle examination, but a low level of teaching self-examination. Counselling on retirement, lifestyle, 'passages' and similar issues was uninfluenced by the instrument.