Developing primary care curricula in preventive medicine: some practical considerations.

I describe a practical approach to developing primary care curricular in preventive medicine, starting with the articulation of a rationale that relates training to current medical education, mortality, medical manpower, and health care system characteristics. I discuss recommended features of the ambulatory care setting for instruction and include automated record systems, practice teams, multidisciplinary staff, faculty role models, conferences and rounds, and needs of low-income populations. Further, I advocate a careful review of the three-year residency curriculum including conferences, rounds, and rotations to identify elements of the desired curriculum on which to build preventive medicine training so as to alter scheduling minimally. I consider longitudinal as well as block rotation experiences. I highlight published resources for defining preventive medicine content areas and recommend local resources for preventive medicine training and for involving residents in personal health promotion. Finally, I offer an example of a family medicine resident experience in breast and cervical cancer screening to illustrate an approach to accomplishing specific objectives for preventive medicine training.     

Suggested guidelines for pharmacotherapy curricula in family medicine residency training: recommendations from the Society of Teachers of Family Medicine Group on Pharmacotherapy

Rational drug use has increasingly received public policy attention in efforts to maintain quality health care at lower costs. Prescribing habits are developed during residency training, and education regarding rational drug use should be an integral part of the residency curricula. Considering that many medical errors in family medicine are related to incorrect medication management, there is need for a focused education in pharmacotherapy. This paper outlines suggested guidelines for pharmacotherapy curricula in family medicine residency training, as recommended by the Society of Teachers of Family Medicine Group on Pharmacotherapy. A pharmacotherapy curriculum should include common conditions managed in family medicine, as well as general principles of pharmacotherapy. This should allow for repeated exposure to core topics over a 3-year cycle and be delivered in various settings (didactic teaching, longitudinal active learning, point-of-care education, and rotations). The curriculum should apply and evaluate pharmacotherapy education according to the six core competencies of the Accreditation Council for Graduate Medical Education (ACGME). Although physician faculty can be responsible for pharmacotherapy education, a clinical pharmacist is uniquely qualified to provide this service. Overall, family medicine residents need comprehensive instruction in pharmacotherapy to develop rational prescribing habits. A structured pharmacotherapy curriculum may assist in achieving this goal and in meeting the ACGME core competencies for residency training.     

The teaching of preventive medicine in American medical schools, 1940–1980

The concept of incorporating prevention into clinical medicine has been addressed by academic medicine since the 1940s. Results reflect the dominant interests of academic medicine over time. This paper reviews this experience, as reflected in national conferences and related activities largely sponsored by the Association of Teachers of Preventive Medicine, and assesses implications for the 1980s. The consensus of the 1940s was that medical education should focus upon quantitative disciplines. Clinical applicability was considered important, but little was developed. Convening in 1952, deans, clinicians, and preventive medicine faculty strongly recommended teaching clinical prevention in “comprehensive care” programs. This movement was eclipsed by research and specialization. Academic preventive medicine focused on residency training and research, culminating in a major conference in 1963. Epidemiology and biostatistics flourished, while teaching clinical prevention received little attention. By 1970, dominant interest shifted to health services policy and research. Currently, some preventive medicine departments have affiliated with primary care training programs, and policy makers are focusing upon prevention. A number of nationally sponsored curriculum development projects deal with preventive aspects of primary care. Under these circumstances, incorporation of prevention into medical practice seems likely to succeed at the academic level. This may in turn stimulate similar occurrences in the medical care system.     

Linking undergraduate medical education to primary health care

Under graduate medical education aims at producing doctors who are competent in preventive, promotive and curative knowledge and skills. The community medicine curriculum in All India Institute of Medical Sciences, New Delhi has been designed with this objective in view. Students are given community oriented training in urban and rural settings whereby students are taught to carry out various activities under the guidance of faculty members. This curriculum has evolved over many years and provides ample exposure to the students to understand the health problems, and health system of the country especially at the primary and secondary level. There is a sequential teaching of community medicine, which starts from fourth semester through internship. Successful training in community medicine lies outside the walls of the department and the involvement of other partners like the community, health systems etc contribute largely.     

Community medicine in the training of family physicians.

Family practice residency programs are encouraged to include community medicine training in their curriculum, but there is little agreement as to what community medicine is or what would constitute appropriate training. Community medicine is most commonly defined as a discipline concerned with the identification and solution of health care problems of communities or other defined populations. The inclusion of training experiences in the identification and solution of health care problems of communities has two basic advantages for family practice residency programs: it fosters a contextual approach in the care of individual patients and it builds knowledge and skills for those who will work with communities in future practices. An example of curricular content is included. A survey was conducted in order to determine what residency programs teach in the field of community medicine. The results show that few of the responding programs include the areas which most clearly relate to community medicine. It is hoped that the report of these results, the rationale presented for including community medicine in the training of family physicians, and the suggested outline of curricular content will further encourage and assist family practice residency programs to incorporate such training in their curricula.     

A threat to the public health workforce: evidence from trends in preventive medicine certification and training

Evidence of a growing need for preventive medicine specialists is the congruence between needed competencies for practice in the current health care environment, as identified by the Council on Graduate Medical Education (COGME) and in other national reports, and the core competencies of preventive medicine residents. The total number of certified specialists in preventive medicine is 6091. The proportion of self-designated preventive medicine specialists among all U.S. physicians is on the decline and the greatest decline has been among those in public health (PH) and general preventive medicine (GPM). In addition, the total number of preventive medicine residents is on the decline, and the decline has been greatest among those training in PH and combined PH/GPM. One of the reasons for this decline has been inadequate funding due to the absence of Medicare graduate medical education (GME) financing for population-based vs. individual patient care services and meager and diminishing Title VII support. A paucity of faculty is apparent in medical schools with residency training and board certification in preventive medicine. Several actions may help reverse this trend and assure adequate numbers of preventive medicine specialists: expansion of Title VII to increase the number of residents receiving stipends and tuition, adding infrastructure support for faculty development and funding of demonstration projects in distance learning and in joint generalist/ preventive medicine residency training. Medicare GME reform should include recognition of population-based services and inclusion of preventive medicine residencies in provisions for "nonhospital-based" training and in up-weighting methodologies for primary care training. Expansion of Veterans Affairs, National Institute for Occupational Safety and Health, and Department of Defense support is also needed as is attention to resident debt reduction.     

Experiences with a combined residency in internal and preventive medicine

BACKGROUND: The importance of integrating preventive medicine training into other residency programs was reinforced recently by the residency review committee for preventive medicine. Griffin Hospital in Derby CT has offered a 4-year integrated internal medicine and preventive medicine residency program since 1997. This article reports the outcomes of that program. METHODS: Data were collected from surveys of program graduates and the American Boards of Internal and Preventive Medicine in 2005-2007, and analyzed in 2007-2008. Graduates rated the program in regard to job preparation, the ease of transition to employment, the value of skills learned, the perceived quality of board preparation, and the quality of the program overall. Graduates rated themselves on core competencies set by the Accreditation Committee for Graduate Medical Education. RESULTS: Since 1997, the program has enrolled 22 residents. Residents and graduates contribute significantly toward quality of care at the hospital. Graduates take and pass at high rates the boards for both for internal and preventive medicine: 100% took internal medicine boards, 90% of them passed; 63% took preventive medicine boards, 100% of them passed). The program has recruited residents mainly through the match. Graduates rated most elements of the program highly. They felt well-prepared for their postgraduation jobs; most respondents reported routinely using preventive medicine skills learned during residency. Graduates either have gone into academic medicine (31%); public health (14%); clinical fellowships (18%); or primary care (9%); or they combine elements of clinical medicine and public health (28%). CONCLUSIONS: Integrating preventive medicine training into clinical residency programs may be an efficient, viable, and cost-effective way of creating more medical specialists with population-medicine skills.     

Preventive practicum training in healthcare organizations. The Meharry model.

BACKGROUND: Practicum training for preventive medicine residents often occurs in agencies whose community is geographically defined and whose governance is closely linked to public election. We were unsure about the financial ability of such departments to support training and are concerned that over-reliance on traditional health departments might not be best for either medically indigent populations or preventive medicine. We, therefore, sought to apply a public health model--based on a strategic partnership between nursing and preventive medicine--to a large health care organization. The result was formation of a mini-health department, suitable for fully accredited preventive medicine practicum training, within the Alvin C. York Veterans Affairs Medical Center, Murfreesboro, TN. This Center serves a defined population of 21,594 patients and about 1600 employees. The theoretical framework for the new department was based on demonstration of a close fit between the competencies expected of preventive medicine physicians by the American College of Preventive Medicine (ACPM) and activities required by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO). Because of JCAHO requirements, many healthcare organizations already pay for preventive medicine services. CONCLUSIONS: By placing preventive medicine training faculty into existing budget slots at our institution, systemwide personnel costs for prevention decreased by about $36,000 per year, even as personnel funding for preventive medicine physicians increased from about $24,000 to $376,000 per year. Moreover, there was dramatic, sustained improvement in 17 indicators of preventive care quality as determined by an external peer review organization. In addition to providing a new venue for training, this model may also improve the quality and reach of preventive services, decreased fixed costs for service delivery, and yield new employment opportunities for preventive medicine physicians.     

Integrating population health into a family medicine clerkship: 7 years of evolution

A population health curriculum using methodologies from community-oriented primary care (COPC) was developed in 1994 as part of a required third-year family medicine clerkship at the University of New Mexico. The curriculum integrates population health/community medicine projects and problem-based tutorials into a community-based, ambulatory clinical experience. By combining a required population health experience with relevant clinical training, student careers have the opportunity to be influenced during the critical third year. Results over a 7-year period describe a three-phase evolution of the curriculum, within the context of changes in medical education and in health care delivery systems in that same period of time. Early evaluation revealed that students viewed the curricular experience as time consuming and peripheral to their training. Later comments on the revised curriculum showed a higher regard for the experience that was described as important for student learning.     

Community Fieldwork Collaboration Between Medical and Social Work Students

This article describes an educational demonstration in interdisciplinary community field experiences between social work and medical students at The University of Kentucky Medical Center at Lexington. The joint training effort involved collaboration between the medical school, the hospital social service department, the school of social work, and community social and health agencies. The pilot program in which students from different professions lived for 6 weeks in outlying rural communities served by the medical center, provided an opportunity: (a) to study the feasibility of combining a broad community health study experience with casework services in a hospital-based educational program and (b) to assess the benefits of early interdisciplinary community and clinical work between future doctors and social workers. Students saw the advantages of cooperative teamwork in studying community problems, and were able to apply classroom theory about community organization to real community situations. The organizational structure and staff resources required to carry out such a demonstration are described, and the implications of the training project are discussed.     

Partnerships creating postgraduate family medicine in Kenya

Culminating a decade-long process, the first family medicine residency program in Kenya, among the first in Africa outside Nigeria and South Africa, was launched in 2005. Three diverse stakeholders are collaborating in their individual and joint missions: Moi University Faculty of Health Sciences (MUFHS), educating medical students to serve rural Kenyans; the Institute of Family Medicine (Infa-Med), a church hospital-based non-governmental organization aiming to introduce family medicine in Kenya; and the Ministry of Health (MoH), working to create an efficient government health care workforce for 32 million Kenyans. MUFHS brings central facilities, enthusiastic academic leadership, and long-term vision. Infa-Med contributes start-up resources, expatriate family medicine faculty, and well-established hospitals for training. MoH is giving political support to the new specialty as well as scholarships to MoH medical officers entering the 3-year residency program leading to the degree of Master of Medicine in Family Health. Among the lessons learned through this process are the importance of melding the missions of all partners, of integrating clinical with community care of the underserved, and of deriving curriculum from African and international evidence on how to marshal available resources to meet Kenya's national needs. Opportunities continue for internal and international collaboration.     

The AMA Residency Training in Adolescent Preventive Services Project: report of the working group. The American Medical Association.

PURPOSE: To improve resident education in provision of adolescent preventive health care. The American Medical Association (AMA) Residency Training in Adolescent Preventive Services Project Working Group convened to identify specific goals and objectives (G&Os) for pediatric and family medicine resident education in adolescent clinical preventive services and recommend strategies to achieve these G&Os. METHODS: Iterative review process involving members of the working group, nine experienced teaching faculty and 16 resident physicians from family medicine and pediatric training programs, and an advisory board. RESULTS: We achieved consensus on appropriate G&Os for pediatric and family medicine residency education in adolescent clinical preventive services. Faculty and residents expressed concerns about achieving G&Os because of challenges to implementing effective training and evaluation strategies. Suggestions for achieving G&Os included development of an adolescent clinical preventive services curriculum and evaluation program that could be adapted for use in a variety of training program structures. Faculty and residents anticipated the success of a training curriculum would be influenced by: (a) availability of adequate numbers of skilled teaching faculty; (b) availability of time and support for faculty development and teaching efforts; and (c) exposure of residents to adequate numbers of adolescent patients in settings where there are clear expectations for delivery of comprehensive preventive services. CONCLUSIONS: The AMA Residency Training in Adolescent Preventive Services Project Working Group presents G&Os for organizing training experiences in adolescent clinical preventive services in family medicine and pediatric residency training programs and recommends strategies to achieve these G&Os.     

Defining Competencies and Performance Indicators for Physicians in Medical Management

The recent and profound changes in the American health care delivery system have created a need for physicians who are trained and willing to assume a high level of responsibility for managing evolving health care organizations. Yet most physicians receive no formal training in medical administration and management because changes in medical school and residency education have lagged behind changes in clinical practice and reimbursement. To avoid haphazard approaches and unnecessary duplication of resources, it is important for physicians involved in managerial medicine to collectively identify competencies in this area needed in the marketplace. The American College of Preventive Medicine (ACPM), with funding from the Health Resources and Services Administration (HRSA), undertook an effort to identify competencies essential for physicians who will fill leadership roles in medical management. Like ACPM’s earlier effort to develop core competencies in preventive medicine, this project drew upon the theoretical model of competency-based education. This article describes the strategy we followed in reaching consensus among a diverse group of physician executives and preventive medicine residency program directors, and includes the list of medical management competencies and performance indicators developed. Recurrent issues that can sidetrack competency development projects are also presented as well as suggestions for overcoming them. The competencies can serve as a framework for expanding current core preventive medicine training in management and administration and for developing new training programs to equip physicians with the special expertise they will need to provide management leadership within the changing landscape of health care delivery.     

Longitudinal and horizontal integration of nutrition science into medical school curricula

The overall goal of our Nutrition Academic Award (NAA) medical nutrition program at Mercer University School of Medicine is to develop, implement and evaluate a medical education curriculum in nutrition and other aspects of cardiovascular disease (CVD) prevention and patient management with emphasis on the training of primary care physicians for medically underserved populations. The curriculum is 1) vertically integrated throughout all 4 y of undergraduate medical education, including basic science, clinical skills, community science and clinical clerkships as well as residency training; 2) horizontally integrated to include allied healthcare training in dietetics, nursing, exercise physiology and public health; and 3) designed as transportable modules adaptable to the curricula of other medical schools. The specific aims of our program are 1) to enhance our existing basic science problem-based Biomedical Problems Program with respect to CVD prevention through development of additional curriculum in nutrition/diet/exercise and at-risk subpopulations; 2) to integrate into our Clinical Skills Program objectives for medical history taking, conducting patient exams, diet/lifestyle counseling and referrals to appropriate allied healthcare professionals that are specific to CVD prevention; 3) to enhance CVD components in the Community Science population-based medicine curriculum, stressing the health-field concept model, community needs assessment, evidence-based medicine and primary care issues in rural and medically underserved populations; 4) to enhance the CVD prevention and patient management component in existing 3rd- and 4th-y clinical clerkships with respect to nutrition/diet/exercise and socioeconomic issues, behavior modification and networking with allied health professionals; and 5) to integrate a nutrition/behavior change component into Graduate Residency Training in CVD prevention.     

The preceptorship,an integral unit of the curriculum in community and family medicine

A curriculum in community and family medicine at the University of Massachusetts Medical School, planned to include a primary care preceptorship as an integral unit, is described. The curriculum has been planned to allow for repeated and increasing exposure of medical students during their undergraduate years to a variety of health care settings within the state. An extensive program of courses is required for all students and consists of a three-week field clerkship in the first year, a field-oriented epidemiology course in the second year, and a six-week field clerkship in the third or fourth year. A preceptorship elective is available to all medical students after they have completed their first two years. Field visits by community and family medicine faculty to the preceptorship site provide overall guidance, facilitate the implementation of objectives, and provide opportunities to strengthen bonds between the practicing physicians of the Commonwealth of Massachusetts and the state medical school. The results to date are discussed.     

Community-based projects in rural internships: an alternative approach

Supervision of medical interns posted to various primary health centres and rural health training centres by specialists in preventive and social medicine and other clinical disciplines is becoming less and less effective for a number of unavoidable reasons. Because of lack of proper and timely guidance, interns feel that during the 6-month rural internship they do not get enough experience of rural life. In order to provide them with learning experiences in community medicine and orient them in the social dynamics of the community, a new approach involving interns in small community-based projects, probably for the first time, was tried on a pilot basis at the Rural Health Training Centre (RHTC), Sirur, a field practice area of B.J. Medical College, Pune, Maharashtra, India. Interns working at RHTC Sirur completed these community-based projects successfully. Identification of problems, study design analysis and drawing conclusions, based on observation, were all undertaken by the interns under the guidance of the staff of the Department of Preventive and Social Medicine, B.J. Medical College. The opinion poll at the end of the rural internship revealed that 76% of interns considered this experience valuable for improving their knowledge and skills, and 56% though that interaction during these projects was beneficial to the community as well. This experience with community-based projects for interns during their rural posting provides them with an opportunity for interaction with the community.     

Impact of a comprehensive health promotion curriculum on physician behavior and attitudes

Physician involvement with health promotion and disease prevention (HP/DP) is essential in the control of diseases in which behavioral risk factors are etiologically important. Yet physician involvement with health promotion is generally perceived as less than optimal. We report that an intensive, multifactorial curriculum introduced into a community hospital family medicine residency program increased physicians' use of preventive strategies with their patients and facilitated their use of specific, easy-to-follow protocols for the management of common problems amenable to health promotion.     

Characterizing Customers at Medical Center Farmers’ Markets

Approximately 100 farmers’ markets operate on medical center campuses. Although these venues can uniquely serve community health needs, little is known about customer characteristics and outreach efforts. Intercept survey of markets and market customers between August 2010 and October 2011 at three medical centers in different geographic regions of the US (Duke University Medical Center, Cleveland Clinic, and Penn State Hershey Medical Center) were conducted. Markets reported serving 180–2,000 customers per week and conducting preventive medicine education sessions and community health programs. Customers (n = 585) across markets were similar in sociodemographic characteristics—most were middle-aged, white, and female, who were employees of their respective medical center. Health behaviors of customers were similar to national data. The surveyed medical center farmers’ markets currently serve mostly employees; however, markets have significant potential for community outreach efforts in preventive medicine. If farmers’ markets can broaden their reach to more diverse populations, they may play an important role in contributing to community health.     

Community-oriented primary care: critical assessment and implications for resident education

BACKGROUND: Community-oriented primary care (COPC) is a systematic approach to health care based on principles derived from epidemiology, primary care, preventive medicine, and health promotion that has been shown to have positive health benefits for communities in the United States and worldwide. METHODS: MEDLINE was searched using the key phrase "community-oriented primary care." Other sources of information were books and other documents. RESULTS AND CONCLUSIONS: Because of lack of predictable reimbursement for COPC services and difficulties encountered incorporating COPC in medical and residency curricula, widespread application of COPC has not occurred. Recent trends in public health initiatives, managed health care, and information technology provide an environment ripe for application of COPC in medical practice. Also, recent recommendations made by the Strategic Planning Working Group of the Academic Family Medicine Organizations and the Association of Family Practice Residency Directors regarding specific community competencies for residency training have direct bearing on COPC and family medicine educators. These trends and recommendations, properly configured, will produce a medical training and practice environment conducive to COPC.