The MD-MPH program at the University of North Carolina at Chapel Hill.

In 1997, the Schools of Medicine and Public Health at the University of North Carolina at Chapel Hill (UNC) developed a formal MD-MPH program, called the Health Care and Prevention (HC&P) Program, located in the Public Health Leadership Program in the UNC School of Public Health. Since then, and especially since 2003, the number of UNC medical students taking a year out of their medical studies to pursue an MPH has increased dramatically. At present, more than 20% of UNC medical students enter an MPH program at some point between entering medical school and leaving for residency.The HC&P Program is designed to introduce clinicians to the population sciences and to create physicians who can think in both individual and population terms. The curriculum is a rigorous, 12-month program that includes a practicum experience and a master's paper. Several of the traditional MPH introductory courses have been redesigned to be more relevant to physicians. The program allows a maximum number of electives and places a value on flexibility so that students, together with faculty, can design the educational experience that best meets their needs. Many members of the faculty of the program themselves have both MD and MPH degrees, and some have dual appointments in the schools of medicine and public health.The authors have begun a longitudinal cohort study of program graduates and other medical graduates to understand the effect of the program on students' perceptions of their competency and their ability to exert leadership in various areas of population health.     

The Medical Humanities at the Northeastern Ohio Universities College of Medicine: historical, theoretical, and curricular perspectives.

The Human Values in Medicine Program (HVM) at the Northeastern Ohio Universities College of Medicine is composed of 120 required hours in medical humanities, social sciences, and behavioral sciences. In addition to a required HVM month in the fourth year when the bulk of the course work is completed, students can also choose from lectures, seminars, and short courses during the first, second, and third years. The broad goal of the HVM program as originally conceived was for students to use the content and skills of the humanities disciplines to reflect on their own and others' values, and to appraise their role in the patient-physician relationship, both in the community and in the larger culture. During the past several years, a cultural studies orientation has also been included, particularly the practice of critical analysis aimed at identifying the inequities and injustices within the doctor-patient relationship, in medical training, and in health care access and delivery in the U.S. and beyond. Current program development includes standardizing a bioethics curriculum for all students and developing a required fourth-year course that all students take during their HVM elective month.     

Teaching about the changing U.S. health care system: an innovative clerkship.

Changes in the U.S. health care system have necessitated modifying the scope and content of existing courses in the medical school curricula. In 1996, the Weill Medical College of Cornell University created a new, integrated public health curriculum to reflect the changes in the ways that medical care is organized, financed, and delivered. Teaching medical students to understand the constantly changing health care system is a primary objective of the new curriculum. As part of this curriculum, the medical college instituted a required public health clerkship that focused on the health care system, to be taken in either the third or fourth year. Students are prepared for the clerkship by taking courses in epidemiology, biostatistics, and evidence-based medicine in the first year and an introduction to the health system in the second year. The two-week clerkship, which may be unique in U.S. medical education, seeks to present an in-depth exposure to issues in health care financing and delivery by means of lectures, panel discussions with experts in the field, seminars, and field assignments to health care organizations and agencies.     

Introducing residents to a career in management: the Physician Management Pathway.

To prepare their students and residents for the practice of medicine in a rapidly changing environment, medical educators must teach the business of medicine as well as the science and art of medicine. Recognizing the value of and demand for physician leaders, the authors sought to introduce residents to diverse aspects of medical administration within the context of an academically rigorous internal medicine residency program. The Physician Management Pathway (PMP) was developed in 1997 to expose interested residents to the management concepts employed by physician managers; to help physician trainees begin to develop the leadership and technical skills they will use as physician managers; to provide career mentoring; to provide experiences that enrich the resident's training in clinical medicine; to enhance resident-directed educational activities; and to produce physicians who can successfully work in any health care environment. The PMP curriculum consists of a monthly seminar series, a preceptorship experience in the second year of residency, and a supervised project in the third year. The program was not designed to provide competency in management, but rather is intended to provide an opportunity for new physicians to explore options in this exciting and changing profession.     

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.     

Models of mental health training for primary care physicians

Of the 15% of the population with DSM III diagnosable disorders, 54% are seen exclusively by their primary care physician or by other health professionals. To understand how primary care physicians are prepared for this task the authors attempted to develop a taxonomy of mental health training programs for primary care physicians by: review of the literature, interviews with program sponsors, review of NIMH training grants, and site visits to teaching programs. From this process six program types were defined: consultation, liaison, bridge, hybrid, autonomous, and postgraduate specialization. The characteristics and emphasis of these model types are described as well as program needs for future training. Competence in psychosomatic medicine, psychophysiologic reactions, and the interactions of biologic, psychologic, and social factors in health and disease can be imparted to primary care physicians by such mental health training program designs.     

The education of the physician

Although the quality of U.S. medical care is at an all-time high, thanks largely to the education and training of American physicians, the nation is in a health care crisis, especially in rural areas and the inner cities. To meet this challenge, change in the education of physicians is required. An important reason for the present crisis is that the selection and education process has encouraged only science- and high-technology-oriented individuals to enter medicine, even though social and behavioral factors are the basis of a majority of today's medical problems. The author realizes that there is little motivation for frequently overburdened faculties and underfunded medical schools to undertake the needed changes; he describes various problems that challenge the existence of the health care system, including the increasing (and well-meaning) involvement in educational matters by legislators and bureaucrats. The author then explores various options for bringing about reform of physician education, including changes in premedical education, in the criteria used for identifying and admitting promising students, and in various aspects of medical education. Such reform could encourage some of the best, brightest, and more broadly educated students to enter the medical profession and could maintain high standards of physician education while fulfilling a public trust and meeting a public need.     

Integrating public health into medical education: community health projects in a Primary Care Preceptorship.

Physicians must integrate care of populations with the care of individual patients to function optimally in today's health care environment. With this understanding, medical school curricula are increasingly addressing the skills and knowledge of public health along with those of clinical medicine. The University of Utah School of Medicine in 1997 revised its four-year curriculum to increase the teaching of topics needed by future physicians, including public health. This report describes one course in the curriculum, the Primary Care Preceptorship (PCP), a fourth-year, six-week required rotation that assists students in learning about the health needs of a community along with providing primary care for its individual residents. Students in the PCP spend approximately 60% of their time in clinical primary care and 40% completing a community health project. In the first year of the PCP, 32 students completed projects on clinical problems, 27 on community health needs assessment, 26 on patient education, and 15 on epidemiology.     

The integrative family medicine program: an innovation in residency education.

The Integrative Family Medicine (IFM) Program is a four-year combined family medicine residency program and integrative medicine fellowship. It was created in 2003 to address the needs of four constituencies: patients who desire care from well trained integrative physicians, physicians who seek such training, the health care system which lacks a conventional integrative medicine training route, and educational leaders in family medicine who are seeking new strategies to reverse the declining interest in family medicine amongst U.S. graduates. The program was designed jointly by the University of Arizona Program in Integrative Medicine (PIM) and family medicine residency programs at Beth Israel/Albert Einstein College of Medicine (AECOM), Maine Medical Center, Middlesex Hospital, Oregon Health & Science University, and the Universities of Arizona and Wisconsin. One or two residents from each of these institutions may apply, and when selected, commit to extending their training by a fourth year. They complete their family medicine residencies at their home sites, enroll in the distributed learning associate fellowship at PIM, and are mentored by local faculty members who have training in integrative medicine. To date three classes totaling twenty residents have entered the program. Evaluation is performed jointly: PIM evaluates the residents during residential weeks and through online modules and residency faculty members perform direct observation of care and review treatment plans. Preliminary data suggest that the program enhances interest amongst graduating medical students in family medicine training. The Accreditation Council of Graduate Medical Education Family Medicine residency review committee has awarded the pilot experimental status.     

An integrated residency in internal and preventive medicine.

The importance of preventive and population-based principles in clinical practice is widely acknowledged. The challenge of imparting these principles in either undergraduate or postgraduate medical education has, however, not been fully met. The necessary skills are provided comprehensively by preventive medicine residency programs, but at the expense of clinical training. Sequential residencies in primary care and preventive medicine, the currently available means of obtaining thorough preparation in both clinical and population-based principles, represent an inefficient, generally unappealing, and non-integrated approach. In response to these concerns, and in an effort to make preventive medicine training appeal to a wider audience, the authors developed and implemented a residency program fully integrating internal and preventive medicine. The program meets, and generally exceeds, the requirements of both specialty boards over a four-year period. The program provides extensive training in clinical, preventive, and public health skills, along with case management and cost-effective care, conferring the MPH degree and leading to dual board eligibility. The model is ideally wed to the demands of the modern health care environment in the United States, is extremely attractive to applicants, and may warrant replication both to train academic and administrative leaders and to raise the standards of preventive and public health practice in primary care.     

Health and disease in context: a community-based social medicine curriculum.

Despite the increasing attention paid to the role of social forces in determining health, most physicians finish their training ill-prepared to address these issues. The authors describe their efforts to fill that training gap for internal medicine residents at Oregon Health and Science University through a community-based social medicine curriculum, designed in 2006 in conjunction with community partners at Central City Concern (CCC), an organization addressing homelessness, poverty, and addiction in downtown Portland, Oregon. The challenge was to develop a curriculum that would (1) fit within the scheduling constraints of an established categorical internal medicine residency program, (2) give all internal medicine residents a chance to better understand how social forces affect health, and (3) help show how they, as health professionals, might intervene to improve health and health care. The authors maintain that by developing this curriculum with community partners--who took the lead in deciding what residents should learn about their community and how they should learn it--the residency program is providing a relatively brief but extremely rich opportunity for residents to engage the personal, social, and health-related issues experienced by clients served by CCC.The authors first provide a brief overview of the curriculum and describe how the principles and practices of community-based participatory research were used in its development. They then discuss the challenges involved in teaching medical residents about social determinants of health, how their academic-community partnership approaches those challenges, and the recently established methods of evaluating the curriculum.     

A portable laboratory test reference for handheld computers: evaluation on an internal medicine clerkship

We provided a laboratory test program for the personal digital assistant (PDA) to a cohort of third year medical students during their internal medicine clerkship. At the end of each rotation, students were interviewed about their experience with the program, and tracking information was downloaded from their PDAs. Students found the program helpful and easy to use, accessed it more often during patient care activities than as a study aid, and considered the program a better way to learn about laboratory tests than formal teaching sessions. The program was accessed an average of 4 or 5 times per week, although individual use was highly variable. There was no relationship between end-of-clerkship examination scores and the number of tests that were accessed. The PDA program is an effective way to introduce laboratory facts and concepts into an internal medicine clerkship.     

Primary care by desire or default? Specialty choices of minority graduates of US medical schools in 1983.

This study was undertaken to determine if US medical school students of different racial/ethnic backgrounds demonstrate similar patterns of evolution of specialty choice between their senior year of medical school and their third postgraduate year. The study identified the specialty choices of US medical school seniors in 1983 through their responses to the Association of American Medical Colleges Graduating Medical Student Questionnaire (GQ). The cohort was classified into three groups: underrepresented minorities, non-underrepresented minorities, and whites. Using these AAMC data as baseline, each racial/ethnic background group was tracked through their third residency year. Comparisons were made between anticipated specialty choices as senior medical students and actual specialties as revealed through residency tracking. The study found that more than 95% of the cohort began residencies in specialties compatible with their GQ choices. Unexpectedly, almost 20% of blacks, Commonwealth Puerto Ricans, and other Hispanics were not in graduate medical education in their third postgraduate year. This group needs to be studied further in order to learn the proportion of these physicians who subsequently completed residency training and the reason(s) for attrition in physicians who did not fulfill minimum training requirements for board certification.     

Addressing health care needs of the Latino community: one medical school's approach.

The Program in Medical Education for the Latino Community (PRIME-LC) at the University of California-Irvine (UCI) School of Medicine was designed to improve health care delivery, research, and policy in underserved Latino communities. Specialized training develops strongly committed physicians with linguistic skills and cultural understanding, enabling them to serve Latino patients. Presently, the health care system's shortage of providers with this expertise renders it unable to address the Latino community's needs adequately. The UCI School of Medicine realized they were proposing a radically different type of program at the onset of this project -- one designed to address the health care needs of a specific ethnic group. Developed with dual goals, PRIME-LC aspires to provide the Latino community with culturally sensitive, Spanish-speaking physicians who are well aware of medical and social conditions prevalent among Latinos, in addition to physicians with a broad understanding of community medicine who are well versed in advocacy and able to become leaders within and outside the Latino community. PRIME-LC must be placed within the context of predicted physician shortages in the United States attributable to the projected population increase in general and, more specifically, within the context of a growing Latino population nationwide. As medical schools prepare to increase their output, programs like PRIME-LC that address society's special needs deserve serious consideration.     

The evolution of a required research program for medical students at the University of Washington School of Medicine.

The concepts and tools clinicians use to understand disease and treat patients are the direct product of basic and applied scientific inquiry. To prepare physicians to participate in this tradition of medical science, the University of Washington School of Medicine (UWSOM) created a research requirement in 1981. The objective was to provide students, during their clinical years of medical school, with first-hand experience in hypothesis-driven inquiry and an understanding of the philosophies and methods of science integral to the practice of medicine. A comprehensive curriculum review in 1998-2000 identified several limitations of this requirement. Although many students completed it successfully, others struggled to find mentors, funding, or time as coursework became more demanding. Other students found they had no interest in or aptitude for the research process itself. Accordingly, UWSOM has reaffirmed its commitment to independent inquiry but expanded the ways in which students can meet the requirement. Three research options are now available under the Independent Investigative Inquiry (III) program, generally completed the summer after students' first year of medical school. These are the hypothesis-driven inquiry, a critical review of the literature, or an experience-driven inquiry in community medicine. The goal of UWSOM is to shape new physicians who can manage rapidly changing medical science, information technology, and patient expectations in clinical practice and/or laboratories. The role of III is to teach students to develop personal methods of acquiring new knowledge and integrate it into their professional lives. Faculty support, program oversight, and funding have been increased.     

Residency education, preventive medicine, and population health care improvement: the Dartmouth-Hitchcock Leadership Preventive Medicine approach.

In 2003, Dartmouth-Hitchcock Medical Center (DHMC) inaugurated its Leadership Preventive Medicine residency (DHLPMR), which combines two years of leadership preventive medicine (LPM) training with another DHMC residency. The aim of DHLPMR is to attract and develop physicians who seek to become capable of leading change and improvement of the systems where people and health care meet. The capabilities learned by residents are (1) leadership -- including design and redesign -- of small systems in health care, (2) measurement of illness burden in individuals and populations, (3) measurement of the outcomes of health service interventions, (4) leadership of change for improvement of quality, value, and safety of health care of individuals and populations, and (5) reflection on personal professional practice enabling personal and professional development. The DHLPMR program includes completion of an MPH degree at The Dartmouth Institute for Health Policy and Clinical Practice (formerly the Center for Evaluative Clinical Sciences) and a practicum during which the resident leads change to improve health care for a defined population of patients. Residents also complete a longitudinal public health experience in a governmental public health agency. A coach in the resident's home clinical department helps the resident develop his or her practicum proposal, which must then be approved by a practicum review board (PRB). Twelve residents have graduated as of July 2007. Residents have combined anesthesia, family medicine, internal medicine, infectious disease, pain medicine, pathology, psychiatry, pulmonary and critical care medicine, surgery, gastroenterology, geriatric psychiatry, obstetrics-gynecology, and pediatrics with preventive medicine.     

Understanding health behavior and speaking out on the uninsured: two leadership opportunities.

The author reviews the growth of managed care and its transforming effect on academic medical centers. He then maintains that in this time of fundamental changes and stress, academic medical centers should not only attend to the organization and financing of the clinical enterprise and the enhancement of biomedical research capacity, but also ask how academic medicine can live up to the unique opportunities and responsibilities it has been entrusted with to improve the health of the public, particularly in two neglected areas. First, if the nation does not expand the research agenda to include social and behavioral factors involved in preventable causes of morbidity and mortality, it will fail to maximize the dividends from the generous public investment in research and fail to learn how to promote healthy personal behavior. Academic medicine can promote such behavior by increasing the science base of prevention and translating into action what is already known, including how to market that knowledge so the public will respond. Second, the number of the medically uninsured is increasing; the largest percentage are the working poor. It is becoming more difficult for teaching hospitals to continue providing a third of the nation's uncompensated care. The author shares a variety of statistics about the uninsured and their care, and maintains that academic medicine, which has been entrusted with the health of the public, can declare that the high number of the uninsured is not acceptable and is a dangerous side effect of the U.S. health care system that must be treated. Doing so will also set an example to medical students and trainees that medicine's responsibility is to all Americans.     

Global health in medical education: a call for more training and opportunities.

Worldwide increases in global migration and trade have been making communicable diseases a concern throughout the world and have highlighted the connections in health and medicine among and between continents. Physicians in developed countries are now expected to have a broader knowledge of tropical disease and newly emerging infections, while being culturally sensitive to the increasing number of international travelers and ethnic minority populations. Exposing medical students to these global health issues encourages students to enter primary care medicine, obtain public health degrees, and practice medicine among the poor and ethnic minorities. In addition, medical students who have completed an international clinical rotation often report a greater ability to recognize disease presentations, more comprehensive physical exam skills with less reliance on expensive imaging, and greater cultural sensitivity. American medical students have become increasingly more interested and active in global health, but medical schools have been slow to respond. The authors review the evidence supporting the benefits of promoting more global health teaching and opportunities among medical students. Finally, the authors suggest several steps that medical schools can take to meet the growing global health interest of medical students, which will make them better physicians and strengthen our medical system.     

Health Care Professionals: A Model for Teaching the Components of Society-Culture-Personality in the Delivery of Care

In recent years, the behavioral sciences have contributed tremendously tot he education of future physicians, dentists, nurses, and other health care professionals. With the inclusion of the behavioral sciences component in the National Board Examination (1972), many medical schools have revised their curricula to include sociology in the training of the future physician. However, the tremendous shortage of qualified social scientists made it difficult to meet the needs of medical schools and health programs in the country.     

Perspective: Creating the next generation of general internists: a call for medical education reform

The United States is faced with an increasing shortage of physicians in the primary care workforce. The number of medical school graduates selecting careers in primary care internal medicine has fallen dramatically since 1985. Although political, financial, and organizational reform of the medical system is necessary, these changes will address only part of the problem. Endeavors designed to ameliorate this current crisis in primary care practice must also address the education and training of future primary care internists. Learners require specialized training in primary care internal medicine to be able to provide high-quality, patient-centered, outcome-oriented care. This article examines the impact of educational interventions in undergraduate medical education (UME) and graduate medical education (GME) on primary care internal medicine career choice and makes suggestions for future educational changes. Suggested UME changes include providing early longitudinal clinical experiences and providing the option for an integrated ambulatory third year of training. Suggested GME changes include early, sustained exposure to general internal medicine and differentiated training tracks for residents interested in primary care. Key among these changes are that medical students and residents must have adequate mentorship from primary care internists and clinical experiences in highly functioning primary care settings established as patient-centered medical homes. Academic centers have a unique opportunity to contribute to these imperatives by reengineering the practice of primary care in a way that embodies the core values of effective, patient-centered care.