The evolution and impact of the national AHEC program over two decades

The national Area Health Education Center (AHEC) program began in 1972 with the purpose of addressing problems of the shortage of physicians and the maldistribution of health professionals. The 40 projects of the program have involved 37 states, 55 medical schools, numerous other health professions schools, and 117 local community AHECs. This 19-month study (1988-1990) was undertaken to systematically assess and clarify the organization, functions, activities, and effects of the national AHEC program over two decades. Data sources were mainly 263 interviews of persons representing the full spectrum of those associated with and participating in AHECs. The findings describe a national network of school and community partnerships that were engaged in planning and implementing educational activities and were responsive to changing needs of health care. The individual AHECs differ in structure and activities as a function of the era in which each began, legislative requirements, and the specific community's needs for health professionals. As organizations, AHECs have unique functions that appear to have benefited the target communities or regions, participating schools, students, and medical school residents. Viability of AHECs in the future will depend on their ability to maintain a focus on health professions education in spite of state or community pressure to provide direct services--both clinical services and public education. At the same time, success will depend on the AHECs' capacity to respond effectively to changing needs of the community and the health care delivery system.     

Factors influencing the development of area health education centers with Texas-Mexico border populations

Area Health Education Centers (AHECs) have been viewed as an appropriate vehicle for implementing new initiatives for training health professionals who will work along the U.S.-Mexico border. Perceptions about this program in Texas were evaluated from July 1988 to June 1989 to identify problems and formulate suggestions that might be of use to academic health science centers (HSCs)--and in particular medical schools--working with Hispanic populations. Interviews were conducted with 116 people: the presidents and/or deans of all eight Texas HSCs and/or medical schools, other deans and faculty, community leaders in five border counties, and state officials. The school and community perspectives about past and present AHEC activities were compared. Some of the barriers were: insufficient components of the health care delivery system to support medical education in severely underserved areas; differing school and community priorities; cultural differences between the school faculty and the community; and feeling among community physicians and dentists that AHECs were a source of competition. The school and community respondents agreed that the AHEC program needs more cooperative planning and training that emphasizes public health education for future AHEC-like activities with border populations.     

Beyond borders: building global health programs at McGill University Faculty of Medicine.

Globalization has irrevocably altered the determinants of health as well as the delivery of health care. Although these changes have been increasingly recognized by governments and funding agencies, and despite the large and growing interest in global health topics among faculty and students, many medical educational programs lack courses or programs in this important area. At McGill University Faculty of Medicine, the Global Health Programs (GHP) were established to build research and training capacity in global health locally and internationally, to stimulate individuals to work in related fields and topics, and to facilitate partnerships with institutions around the world. These goals are addressed through programs that foster communication among interested faculty and students; provide resources such as project databases and easily accessed, centrally located reference materials; and provide both financial and consultative support for faculty and student initiatives. Important lessons learned in building GHP at McGill include (1) the need for a dedicated senior faculty member to lead the program while promoting activities and initiatives, (2) the need for resources to begin new projects, and (3) a willingness to work with others to achieve common goals. Most medical schools already have faculty engaged in and students interested in global health activities. By bringing interested individuals together with a modest infusion of additional resources and creativity, it is possible to develop programs that provide exciting global health educational opportunities for the medical school community and beyond.     

The UCSF Academy of Medical Educators.

The Academy of Medical Educators at the University of California, San Francisco (UCSF), was established in 2000 to (1) foster excellence in teaching, (2) support teachers of medicine, and (3) promote curricular innovation. A membership organization, it recognizes five categories of educational activity: direct teaching, curriculum development and assessment of learner performance, advising and mentoring, educational administration and leadership, and educational research. Excellent medical student teaching and outstanding accomplishment in one or more areas of educational activity qualify a teacher for membership. Candidates prepare a portfolio that is reviewed internally and by national experts in medical education. Currently 37 faculty members, 3% of the entire school of medicine faculty, belong to the academy. The academy's innovations funding program disburses one-year grants to support curricular development and comparisons of pedagogical approaches; through this mechanism, the academy has funded 20 projects at a total cost of $442,300. Three fourths of expended funds support faculty release time. Faculty development efforts include promotion of the use of an educator's portfolio and the establishment of a mentoring program for junior faculty members built around observation of teaching. The Academy of Medical Educators vigorously supports expanded scholarship in education; the academy-sponsored Education Day is an opportunity for educators to present their work locally. Recipients of innovations-funding program grants are expected to present their work in an appropriate national forum and are assisted in doing this through quarterly scholarship clinics. The Academy of Medical Educators has been well received at UCSF and is enhancing the status of medical education and teachers.     

Addressing physician shortages in New Mexico through a combined BA/MD program.

The University of New Mexico School of Medicine and College of Arts and Sciences developed its combined BA/MD degree program, which will increase the medical school class from 75 students to 100 in the fall of 2010, to address the critical issue of physician shortages in underserved New Mexico. The program, which began operation at the undergraduate (i.e., college) level in 2006, expands opportunities in medical education for New Mexico students, especially those from rural and underserved minority communities, and prepares them to practice in underserved areas of New Mexico. In the BA/MD program, students will earn a bachelor of arts, a medical degree, and a proposed certificate in public health. A challenging liberal arts curriculum introduces the principles of public health. Students have unique rural medicine and public health preceptorship opportunities that begin in the undergraduate years and continue throughout medical school. Students work with a community physician mentor in summer service-learning projects during the undergraduate years, then they return for required rural medicine rotations in the first, third, and fourth years of medical school. Simultaneously, the classroom curriculum for these rural medicine experiences emphasizes the public health perspective. High priority has been placed on supporting students with academic advising and counseling, tutoring, supplemental instruction, on-campus housing, and scholarships. The program has received strong support from communities, the New Mexico state legislature, the New Mexico Medical Society, and the faculties of arts and sciences and the school of medicine. Early results on the undergraduate level demonstrate strong interest from applicants, retention of participants, and enthusiasm of students and faculty alike.     

Making it work: the evolution of a medical educational fellowship program.

Longitudinal programs to enhance the educational skills of medical school faculty are present in many medical schools and academic health centers. Multiinstitutional programs are less common. Three health professions schools, Baylor College of Medicine, The University of Texas Medical School at Houston, and The University of Texas Dental Branch have jointly sponsored the Educational Scholars Fellowship Program (ESFP) since 2003. The evolution of this program, from one that addressed the faculty educator development needs of one medical school in the mid-1990s to a more flexible model that includes faculty and fellows from three institutions, reflects the changing needs of faculty as well as those of other health professions schools. The ESFP's strengths lie in the effective use of resources across three schools; the opportunity for an interinstitutional and interdisciplinary collaborative network; the flexibility of the curriculum offerings; and the positive impact on fellows' knowledge, skills and leadership in medical and dental education. The evolution of this program represents a cost-effective and educationally sound response to the changing needs of faculty educators.     

Linking cultural competency and community service: a partnership between students, faculty, and the community.

OBJECTIVE: The purpose of the migrant health initiative is to give medical students the opportunity to provide clinical services, at appropriate levels of training, to a population that reflects a different ethnic and economic background than medical students typically see in the clinical setting. This initiative integrates concepts of cultural competency with experiential learning. DESCRIPTION: The migrant health initiative provides an infrastructure for a cultural competency educational program in the first two years of medical school within an essentials of clinical medicine course (ECM). The ECM course emphasizes the impacts of family, society, and community on the delivery of patient health care. Experience in the provision of clinical care to migrant workers provides an exceptional opportunity to expose students to a medically underserved, diverse group of people and to provide care to persons with a different language. The program was developed from grass-roots initiatives of students and the region's Area Health Education Center (AHEC). Historically, migrant workers provide the majority of the labor for harvesting onions in southeast Georgia. In April 2000, the regional AHEC organized a one-day clinic for migrant workers, staffed by one local physician and allied health students. Care was provided to over 400 laborers. As a result of the response by the migrant workforce, the AHEC developed a partnership with the local community to expand the health care services to this underserved group. Five medical students, working with the school's associate dean for curriculum and local AHEC, had observed a migrant health clinic organized by the AHEC and were seeking ongoing community service opportunities. Based on the interest and enthusiasm of the students, a faculty-supervised migrant health elective was developed for first- and second-year students. The number of students who wanted to take the elective exceeded the available opportunities. The ECM course will be enhanced with an integrated and longitudinal curriculum that focuses on migrant health care; the revised ECM course will provide students with the knowledge, skills, attitudes, and behaviors to care for individuals from different cultures. First-year students will be able to volunteer to work in the program. Second-year students will participate in at least one migrant health clinic, traveling only three hours but providing a different world with medical care. In addition, the opportunities for medical students to participate in a community health initiative and to work with nursing and allied health students will enhance their public health knowledge and their team and leadership skills. DISCUSSION: The partnership between students, faculty, and the community provides the mechanism to thoughtfully develop and integrate cultural issues and experiences into the curriculum. Students have recently received a Caring for Community five-year grant from the Association of American Medical Colleges. Program expansions will continue into the third-year medicine clerkship and include a senior elective. The program expansions will result in a migrant health initiative that will be coordinated; comprehensive; and expand student knowledge, skills, and experiences in cultural health care.     

Emergency preparedness: addressing a residency training gap.

As the importance of physician involvement and leadership in crisis preparedness is recognized, the literature suggests that few physicians are adequately trained to practice effectively in a large-scale crisis situation. A logical method for addressing the emergency preparedness training deficiency identified across several medical specialties is to include disaster and emergency preparedness training in residency curricula.In this article, the authors outline the development and implementation of an emergency preparedness curriculum for the Johns Hopkins General Preventive Medicine Residency (JHGPMR) from 2004 to 2006. The curriculum consists of two components. The first was developed for the academic year in the JHGPMR and includes didactic lectures, practical exercises to apply new knowledge, and an opportunity to integrate the knowledge and skills in a real-world exercise. The second, developed for the practicum year of the residency, includes Web-based lectures and online content and culminates in a tabletop preparedness exercise. Topics for both components include weapons of mass destruction, risk communication and personal preparedness, aspects of local emergency response planning, and mental health and psychological aspects of terrorism.On the basis of the emergency preparedness training gap that has been identified in the literature, and the success of the three-year experience in implementing a preparedness training curriculum in the JHGPMR, the authors recommend incorporation of competency-based emergency preparedness training for residencies of all specialties, and offer insights into how the described curriculum could be adapted for use in other residency settings.     

Faculty development for educational leadership and scholarship.

The Medical Education Scholars Program (MESP) at the University of Michigan Medical School is designed to develop leaders in medical education. The program's goals are to enable faculty to provide curriculum direction, improved teaching, educational research, and development, and institutional leadership at all levels of medical education. This one-year program uses a variety of educational methods and provides a broad curriculum in educational theory, assessment and evaluation, research design and methods, teaching-skills development, and educational leadership. Faculty are admitted on a competitive basis and one half-day per week of release time is funded as part of the program. Salient outcomes of the program (promotions, educational research and development, curriculum leadership, and educational scholarship) were measured in a pre- and post-program design in which each scholar acted as his or her own control. There were major increases in promotions and educational awards, new educational responsibilities, and new educational programs. A particularly important outcome was the emergence of educational scholarship in the professional portfolios of the program scholars in the form of peer-reviewed presentations and publications and educational grant funding. A cost-outcome analysis indicates that these multi-year outcomes were obtained from a one-time investment of approximately $21,000 per graduating scholar. This evaluation indicates that intensive faculty development programs can have measurable impacts on the careers of the participants and the institutional environment.     

Fifteen years of aligning faculty development with primary care clinician-educator roles and academic advancement at the Medical College of Wisconsin.

Starting in 1991, the Medical College of Wisconsin's (MCW) primary care-focused faculty development programs have continuously evolved in order to sustain tight alignment among faculty members' needs, institutional priorities, and academic reward structures. Informed by literature on the essential competencies associated with academic success and using educational methods demonstrated to achieve targeted objectives, MCW's initial 1.5-day per month comprehensive faculty development programs prepared faculty as clinician-researchers, leaders, and educators. As institutional priorities and faculty roles shifted, a half-day per month advanced education program was added, and the comprehensive faculty development program transitioned to its current half-day per month program. Using a modular approach, this program focuses exclusively on clinician-educator competencies in curriculum, teaching, leadership, evaluation, and learner assessment. Instructional methods combine interactive, face-to-face sessions modeling a range of instructional strategies with between-session assignments now supported through an e-learning platform. All participants complete a required project, which addresses a divisional or departmental need, meets standards associated with scholarship, and is submitted to a peer-reviewed forum. To date, over 115 faculty members have enrolled in MCW's faculty development programs. Program evaluation over the 15-year span has served to guide program revision and to provide clear evidence of program impact. A longitudinal evaluation of comprehensive program graduates from 1993 to 1999 showed that 88% of graduates' educational projects were implemented and sustained more than one year after program completion. Since 2001, each participant, on average, attributes more than two peer-reviewed presentations and one peer-reviewed publication to program participation. Based on 15 years of evaluation data, five tenets associated with program success are outlined.     

Tufts Health Sciences Database: lessons, issues, and opportunities.

The authors present their seven-year experience with developing the Tufts Health Sciences Database (Tufts HSDB), a database-driven information management system that combines the strengths of a digital library, content delivery tools, and curriculum management. They describe a future where online tools will provide a health sciences learning infrastructure that fosters the work of an increasingly interdisciplinary community of learners and allows content to be shared across institutions as well as with academic and commercial information repositories. The authors note the key partners in Tufts HSDB's success--the close collaboration of the health sciences library, educational affairs, and information technology staff. Tufts HSDB moved quickly from serving the medical curriculum to supporting Tufts' veterinary, dental, biomedical sciences, and nutrition schools, thus leveraging Tufts HSDB research and development with university-wide efforts including Internet2 middleware, wireless access, information security, and digital libraries. The authors identify major effects on teaching and learning, e.g., what is better taught with multimedia, how faculty preparation and student learning time can be more efficient and effective, how content integration for interdisciplinary teaching and learning is promoted, and how continuous improvement methods can be integrated. Also addressed are issues of faculty development, copyright and intellectual property, budgetary concerns, and coordinating IT across schools and hospitals. The authors describe Tufts' recent experience with sharing its infrastructure with other schools, and welcome inquiries from those wishing to explore national and international partnerships to create a truly open and integrated infrastructure for education across the health sciences.     

Promoting academic excellence through leadership development at the University of Washington: the Teaching Scholars Program.

The University of Washington Teaching Scholars Program (TSP) was established in 1995 to prepare faculty for local and national leadership and promote academic excellence by fostering a community of educational leaders to innovate, enliven, and enrich the environment for teaching and learning at the University of Washington (UW). Faculty in the Department of Medical Education and Biomedical Informatics designed and continue to implement the program. Qualified individuals from the UW Health Sciences Professional Schools and foreign scholars who are studying at the UW are eligible to apply for acceptance into the program. To date, 109 faculty and fellows have participated in the program, the majority of whom have been physicians. The program is committed to interprofessional education and seeks to diversify its participants. The curriculum is developed collaboratively with each cohort and comprises topics central to medical education and an emergent set of topics related to the specific interests and teaching responsibilities of the participating scholars. Core sessions cover the history of health professions education, learning theories, educational research methods, assessment, curriculum development, instructional methods, professionalism, and leadership. To graduate, scholars must complete a scholarly project in curriculum development, faculty development, or educational research; demonstrate progress towards construction of a teaching portfolio; and participate regularly and actively in program sessions. The TSP has developed and nurtured an active cadre of supportive colleagues who are transforming educational practice, elevating the status of teaching, and increasing the recognition of teachers. Graduates fill key teaching and leadership positions at the UW and in national and international professional organizations.     

Enhancing behavioral science education at the Ohio State University College of Medicine.

The social and behavioral sciences play key roles in patient health outcomes. Given this reality, successful development of social and behavioral science curricula in medical education is critically important to the quality of patients' lives and the effectiveness of health care delivery systems. The Institute of Medicine, in a recent report, recommended that medical schools enhance their curricula in these areas and identified four institutions as "exemplars" of social and behavioral science education. The authors describe an ongoing curriculum development and improvement process that produced one such exemplary program at The Ohio State University College of Medicine.The authors provide a historical perspective on behavioral science education, discuss issues that led to curricular change, and describe the principles and processes used to implement reform. Critical factors underlying positive change are addressed: increase active learning, recruit a core group of small-group facilitators who are primary care physicians, diversify teaching methods, support student-directed educational initiatives, enhance student-teacher relationships, centralize course administration, obtain funding, implement a faculty development program, and apply curriculum quality improvement methods. Outcome data from evaluations completed by both students and small-group physician faculty are presented, and future directions regarding further revision are outlined. The authors believe that the strategies they describe can be applied at other institutions and assist behavioral science educators who may experience the challenges typically encountered in this important field of medical education.     

Development and implementation of an online master's degree in education program for health care professionals.

Technological advances, especially the Internet and the World Wide Web, have drastically changed educational practices by reforming the concept of education and knowledge transmission at a distance. Professionals in all disciplines have begun using this advanced technology to expand the number of learning opportunities for intellectual growth and professional development. As a result, many universities and educational institutions now offer online higher degree programs to provide opportunities for nontraditional students who have difficulty attending scheduled, campus-based classes. In medicine, a need has been identified for advanced graduate studies in education to develop the next generation of medical educators and to train them in educational research methods to validate their educational efforts. This need was identified by both informal needs assessment at local, regional, and national faculty development meetings and more formal literature review and government survey. The faculty development team of Cincinnati Children's Hospital Medical Center (Department of Pediatrics, University of Cincinnati College of Medicine) collaborated with the College of Education to develop an online Master's Degree in Education for health care professionals. The program was designed to apply these advanced technologies in order to make the program flexible and accessible to health care professionals whose busy schedules preclude more traditional, in-class graduate programs. This article presents how this program evolved and the problems, challenges, and solutions associated with the development and implementation of the program.     

Development of an interdisciplinary women's health training model.

In response to expanded residency training requirements in women's health, faculty from internal medicine, obstetrics/gynecology, and psychiatry at Yale University School of Medicine established an interdisciplinary women's health training and education model, the Interdisciplinary Women's Health Clinic (IWHC). The model was one component of a larger, comprehensive women's health program at Yale funded by the Department of Health and Human Services between 1996 and 2000 under the National Centers of Excellence in Women's Health (CoE) designation. This article describes the structure and function of the model, its value to residents and the institution, and its limitations that led to its closure when Department of Health and Human Services support ended. The IWHC was designed as a consultation service that augmented the primary care provided to low-income, minority-group women in an established outpatient primary care setting. An interdisciplinary team of residents and faculty provided and coordinated a range of services for patients and participated in a weekly core curriculum. The model was an important resource to residents and provided high-level integrated care to patients. The combined educational experience helped refine a core interdisciplinary women's health curriculum. Despite these benefits, the IWHC could not be sustained outside the financial and programmatic structure of the larger CoE program. This experience suggests that longitudinal models where residents from different disciplines train in a shared educational and clinical setting may be more durable. Interdisciplinary models are effective ways to train residents and provide integrated care to women. The model's success depends on highly developed collaborative relationships between faculty, nonclinical sources of support, and long-term institutional commitment.     

Clinical academies: innovative school-health services partnerships to deliver clinical education.

During the past five years (2001-2006), the University of Bristol Medical School has developed and implemented a new model for delivering clinical education: the clinical academy. The principal features of the model are (1) having both in-Bristol and out-of-Bristol campuses for clinical education, (2) innovative partnerships with local health care providers, (3) local leadership of educational delivery, and (4) the recruitment and training of new cadres of clinical teachers.The seven clinical academies consist of two academies based in traditional acute-care teaching hospitals in the city of Bristol and five academies in the surrounding counties. The same Bristol curriculum is delivered in every clinical academy by locally recruited hospital specialists and family physicians. Each academy is led by an academy medical dean, who has local responsibility for program delivery, quality assurance, academic and personal support for students, and finances on behalf of the university.Medical students rotate between clinical academies every half academic year, alternately based in and outside of Bristol. They learn clinical medicine and develop clinical competence as apprentice members of a local multiprofessional learning community. The medical school now has enough high-quality clinical placements to accommodate increasing numbers of medical students whilst keeping a "human-scale" educational environment.Clinical academies are thus the key components of a decentralized system of curriculum delivery; they differ in concept and purpose from the new academies of medical educators in the United States that offer a centralized focus for the educational mission.     

Founding a new College of Medicine at Florida State University.

In 2000, the Florida State University (FSU) College of Medicine was founded, becoming the first new allopathic medical school in the United States in over 20 years. The new medical school was to use community-based clinical training for the education of its students, create a technology-rich environment, and address primary care health needs of Florida's citizens, especially the elderly, rural, minorities, and underserved. The challenges faced during the creation of the new school, including accreditation and a leadership change, as well as accomplishments are described here. The new school admits a diverse student body made possible through its extensive outreach programs, fosters a humane learning environment through creation of student learning communities, has a distributed clinical training model-with clinical campuses in Orlando, Pensacola, Sarasota and Tallahassee, and with 70% of training occurring in ambulatory settings-and utilizes 21st-century information technology. The curriculum focuses on patient-centered clinical training, using the biopsychosocial model of patient care throughout the entire medical curriculum, promotes primary care and geriatrics medicine through longitudinal community experiences, relies on a hybrid curriculum for delivery of the first two years of medical education with half of class sessions occurring in small groups and on a continuum of clinical skills development throughout the first three years, and uses an interdisciplinary departmental model for faculty, which greatly facilitates delivery of an integrated curriculum. The first class was admitted in 2001 and graduated in May 2005. In February 2005, the FSU College of Medicine received full accreditation from the Liaison Committee on Medical Education.     

Development of the medical humanities program at East Carolina University

The medical humanities program at East Carolina University School of Medicine has 50 contact hours with medical students in the required curriculum, fourth-year electives that are well-subscribed (47% of the members of the class of 1989 took one or more), and programs for residents, fellows, and faculty. The author discusses several crucial decisions made in the first year of the program (1978-79) that affected the nature and development of the program: first, to begin the medical humanities courses in the preclinical required curriculum and use these courses as a base to build on in the clinical years; second, to develop a program through all years of training while preserving time for faculty research; third, to arrange for program faculty to team-teach with clinical faculty; fourth, to show the importance of the humanities programs and courses by the way in which they were constructed and situated in the curriculum; and fifth, to seek primarily to teach a method of inquiry.     

Difficult conversations in health care: cultivating relational learning to address the hidden curriculum.

The authors describe the philosophy and pedagogical approach of an innovative educational program, grounded in principles of relational learning and designed to improve the preparedness of health care professionals for engaging in challenging conversations with patients and families. The Program to Enhance Relational and Communication Skills (PERCS) is a project of The Institute for Professionalism and Ethical Practice at Children's Hospital Boston, developed in collaboration with Education Development Center, Inc. The one-day workshop is interdisciplinary in its structure, includes practitioners with varying levels of professional experience, uses trained actors to portray patients and family members, and involves learners in improvised case scenarios. The program responds to several developments in contemporary health care: medical education reform, changing definitions of professional competence, and calls for greater attention to qualities of compassion, trust, and respect in practitioners' relationships with patients and families. The program's pedagogy responds to these developments by creating a safe climate for relational learning, by enacting emotionally challenging and ethically salient case scenarios, and by integrating patient and family perspectives in novel and substantive ways. By creating a curriculum and learning environment that explicitly embraces the moral experience of learners, the program's developers aim to exert a countercultural influence on the dehumanizing effects of the hidden curriculum.     

The Health Science Institute: An Experience in Learning

The Health Science Institute of Howard University was initiated during the summer of 1973 by students and faculty members in the Colleges of Liberal Arts and Pharmacy and Pharmacal Sciences to address one of the major problems related to the overall poor status of health-care delivery for residents of the nation''s underserved areas—the critical health manpower shortage.