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.     

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.     

Career choices of general preventive medicine residency graduates: 1981-1986

To identify career choices made by recent graduates of general preventive medicine residency programs, all funded residency programs in general preventive medicine (excluding federal and military programs) were surveyed. Eighty-two percent of programs responded and reported on the career choices of 241 graduates who graduated from 1981 to 1986. In order of preference, the categories of career choice were: program activities (36.5%), teaching (19.1%), clinical services (17.0%), and research (6.2%). About one-fifth (21.2%) chose other activities. The number of graduates more than doubled between the periods 1981-1983 and 1984-1986. There was a threefold increase in the percentage of graduates involved primarily in research; however, there was a 33% decrease in the percentage of graduates who became professional academicians.     

Preventive medicine residents: a national survey.

Little is known about those physicians who pursue graduate medical education in preventive medicine, including aerospace medicine, general preventive medicine and public health, and occupational medicine. We surveyed resident physicians about their academic background, financial environment, clinical activities, and professional goals. A total of 147 residents (30%) responded from a population of 498 residents. The data suggest a lack of available information about preventive medicine training and careers among medical students who subsequently pursue such training. Their economic environment is extremely diverse, with a wide range of salary, "moonlighting" hours, educational loans, and service obligations. Although the median annual salary ($24,700) is similar to the national average resident salary, 32% of respondents earned less than $20,000, and 95% have educational debts averaging $30,900. Sixty-two percent of respondents perform clinical work in their residency, whereas 76% desire future clinical work as part of their practice. This gap is most pronounced in general preventive medicine and public health. The residents express a wide range of interests in future practice of preventive medicine; 54% are interested in government work, and 33% desire academic careers.     

健康中国战略下临床医学培养方案之预防医学课程体系现况研究

目的 了解健康中国背景下我国各高校临床医学培养方案中预防医学课程设置现况。方法 抽取全国各区域共36份临床医学专业培养方案进行统计分析。内容包括基本信息、培养目标涉及预防理念的情况、预防医学课程开设情况等。结果 所有培养方案中,22份（61%）在培养目标中未提及预防或群体健康;只有1所高校将预防医学与基础医学、临床医学一起列为主干学科。预防医学核心课程（卫生学、医学统计学、流行病学、临床流行病学、循证医学和社会医学）的总学时数从80～252不等,平均为（156.7±43.2）学时。预防医学课程占总课时数的百分比平均为4.3%±1.1%,最低的仅占2.5%,最高的也只占7.5%,均不足总课时数的10%。各高校之间预防医学各门课程的学时数差异较大。结论 现有临床医学专业人才培养方案中预防理念渗透不足,预防医学课程学时数占比极低,各高校预防医学课时数差异较大。加强新时代临床医学生预防理念的培养迫在眉睫,建议从强化预防为主的观念、完善临床医学课程体系、强化预防与临床融合发展和注重临床研究能力提升4个方面不断完善临床医学专业人才培养方案。     

A randomized controlled trial of an online immunization curriculum

IntroductionImmunization education for physicians-in-training is crucial to address vaccine concerns in clinical practice. Vaccine education is not standardized across residency programs. The Collaboration for Vaccination Education and Research (CoVER) team developed an online curriculum for pediatric (Peds) and family medicine (FM) residents.MethodsA cluster randomized controlled trial (RCT) was performed during the 2017–2018 academic year to evaluate the CoVER curriculum. A convenience sample of residency institutions were randomly allocated to the intervention or control group, with stratification by residency type. The intervention, the CoVER curriculum, consisted of four online modules and an in-person training guide. Control sites continued with their standard vaccine education. Pre-intervention and post-intervention surveys were emailed to residents in both groups. The primary outcomes compared between groups were changes in “vaccine knowledge,” “vaccine attitudes/hesitancy,” and “self-confidence” in immunization communication. The team assessing outcomes was unblinded to assignments. Hierarchical general linear model was used to adjust for residency type and residency year; residency site was modeled as a random effect.ResultsOverall, 1444 residents from 31 residency programs were eligible to participate (734 intervention, 710 control). The pre-intervention response rate was 730 (51%) and post-intervention was 526 (36%). Average knowledge scores increased from pre-intervention (control 53%; CoVER 53%) to post-intervention (control 58%; CoVER 60%). Increases in vaccine knowledge among FM residents were greater for CoVER compared to controls (p = 0.041). Vaccine hesitancy was more common among FM (23%) than Peds (10%) residents. In all three residency years, residents in the CoVER group showed greater increases in self-confidence in ability to discuss vaccines with parents/patients (p < 0.03) compared to control group.ConclusionThe CoVER curriculum is an effective model to standardize immunization education of physicians-in-training. This RCT demonstrated the effectiveness of the CoVER curriculum to improve resident confidence in their ability to discuss vaccines with parents and patients.     

A survey of internal and family medicine residents: Assessment of disability-specific education and knowledge

BackgroundThe literature suggests that primary care physicians are inadequately educated in the care of people with disabilities. No study to date has evaluated whether internal medicine (IM) and family medicine (FM) residents have received disability-specific education or their level of comfort in caring for people with physical disabilities.ObjectivesTo assess IM and FM residents’ receipt of disability-specific education during medical school and residency; to evaluate their self-reported comfort in managing secondary conditions associated with physical disabilities and in coordinating therapies and services for individuals with disabilities; to gauge their interest in receiving disability-specific education.MethodsAn on-line survey distributed to residents at a convenience sample of ten academic IM and FM residency programs in the northeastern United States. Participants (n = 176) were asked about their socio-demographic and training-specific characteristics and their self-assessed ability to manage secondary conditions associated with physical disabilities and coordinate care and services for individuals with disabilities. Chi Square tests were used to compare participant characteristics and outcomes.ResultsFew participants had received disability-specific education during medical school or residency (34.6% and 11.2%, respectively), and nearly all (96.0%) expressed interest in receiving more. Small minorities reported feeling comfortable managing common secondary conditions or in coordinating therapies and services for individuals with disabilities.ConclusionAlthough one-fifth of adult Americans have a disability, few of our participating IM and FM residents had received disability-specific education or felt comfortable managing the care of people living with disabilities. Our results indicate a need to develop and disseminate disability-specific curricula.     

Postgraduate preventive medicine: Where do we stand today

It appears that the specialty of preventive medicine is declining as a viable specialty, with inadequate numbers of practitioners and with a declining number of physicians entering residency training programs. However, additional data are needed to make rough estimates of the level of need in the future. Even without that data, we must begin to address the potential shortage in trained manpower, because there is a trend that cannot be ignored pointing to a potential shortage. Several points must be pursued. All medical students must be exposed to the excitement we all feel about preventive care. Our teaching programs in medical schools must be strengthened to assure that there is rigor in these programs and that the potential of preventive medicine is conveyed. It is imperative to examine the field to discover why so many of our self-designated specialists in preventive medicine are not board-certified. Obviously one reason could be that a hungry job market is taking individuals who have not been trained in preventive medicine; another reason could be that for some reason specialists in the field of preventive medicine may feel that board-certification is not necessary for their career goals. This issue raises many questions about the importance of academic training in preventive medicine. It also points to the importance of addressing mid-career training needs on the part of those self-designated specialists. The question of financing must be addressed as well. Efforts must be developed to assure that the preventive field is reimbursed by major third-party payors, Medicare and Medicaid. Perhaps through these reimbursement mechanisms a way could be found to provide, at least in part, resident stipends. In addition, other mechanisms must be developed to provide support for residents in training in preventive medicine. If as a people we are to fulfill our potential of healthiness and achieve the Objective For Health Promotion and Disease Prevention, we must have trained personnel to do the job.     

Twenty Years of the Ryan Residency Training Program in Abortion and Family Planning

ObjectiveTo summarize the effects of routine, opt-out abortion and family planning residency training on obstetrics and gynecology (ob-gyn) residents’ clinical skills in uterine evacuation and intentions to provide abortion care after residency.MethodsData from ob-gyn residency programs supported during the first 20 years of the Kenneth J. Ryan Residency Training Program in Abortion and Family Planning were analyzed. Postrotation surveys assessed residents’ training experiences and acquisition of abortion care skills. Residency program director surveys assessed benefits of the training to residents and the academic department from the educators’ perspectives.ResultsA total of 2775 residents in 89 ob-gyn programs completed postrotation surveys for a response rate of 72%. During the rotation, residents – including those who only partially participated – gained exposure to and skills in first- and second-trimester abortion care. Sixty-one percent intended to provide abortion care in their postresidency practice. More than 90% of residency program directors (97.5% response rate) reported that training improved resident competence in abortion and contraception care and 81.3% reported that the training increased their own program's appeal to residency applicants.ConclusionOver 20 years, the Ryan Program has supported programs to integrate abortion training to give ob-gyn residents the skills and inspiration to provide comprehensive reproductive health care, including uterine evacuation and abortion care, in future practice. Residency program directors noted that this integrated training meets resident applicants’ expectations.ImplicationsRyan Program residents are trained to competence and are prepared, both clinically and in their professional attitudes, to care for women's reproductive health.     

Regaining the preventive medicine edge: training for 2000 and beyond

We review the state of preventive medicine in the context of four factors that have eroded the influence and effectiveness of the specialty: (1) historical; (2) cultural; (3) political-economic; and (4) changing epidemiological and demographic factors. We address the implications for public and medical peer recognition of preventive medicine, for funding of residency programs, and for recruitment of medical students. We outline five objectives for preventive medicine training as steps to improve the response of the specialty to the above factors and to regain its edge. Also, we propose two specific innovative training programs to partially meet these objectives: a cross-cultural public health exchange and a preventive medicine fellowship in policy and public administration. We discuss the pertinence of these programs in terms of reversing preventive medicine's growing obsolescence.     

Contractual arrangements between residency programs and HMOs.

BACKGROUND. Although one out of seven health maintenance organizations (HMOs) is directly involved in graduate medical education (GME), either as an accredited sponsoring organization or through a contractual agreement with an academic medical center or teaching hospital to serve as an ambulatory rotation site, relatively little is known about the extent to which HMOs have provider contracts with faculty or residents of GME programs. Such provider contracts are not agreements to collaborate on the education of residents, but rather contractual arrangements under which individual physicians or groups (who happen to be residents or faculty) agree to provide services to HMO enrollees in return for some form of compensation. METHODS. In 1990, the Group Health Association of America conducted a survey of a sample of residency training programs in family medicine, internal medicine, and pediatrics to ascertain the extent to which (1) residents and faculty of residency training programs are participating physicians in HMOs; and (2) HMO enrollees are serving as the patient base for GME in ambulatory settings. RESULTS. Overall, 42% of the residency program respondents indicated that they contract with HMOs to provide services to enrollees. Nearly two thirds (64%) of family practice programs have provider contracts as compared with 28% of pediatrics programs and 24% of internal medicine programs. Provider contracts with independent practice associations are by far the most common, followed by group, network, and staff model contracts, in that order. CONCLUSIONS. It is apparent that provider contractual arrangements between HMOs and primary care residency programs are quite common, especially in the area of family practice. These contractual arrangements have probably resulted in a more predictable and stable patient revenue base for residency programs. The long-term effects on provider practice styles and the financing of graduate medical education are less clear.     

The cost-effectiveness of training US primary care physicians to conduct colorectal cancer screening in family medicine residency programs

BackgroundDemand for a wide array of colorectal cancer screening strategies continues to outpace supply. One strategy to reduce this deficit is to dramatically increase the number of primary care physicians who are trained and supportive of performing office-based colonoscopies or flexible sigmoidoscopies. This study evaluates the clinical and economic implications of training primary care physicians via family medicine residency programs to offer colorectal cancer screening services as an in-office procedure.MethodsUsing previously established clinical and economic assumptions from existing literature and budget data from a local grant (2013), incremental cost-effectiveness ratios are calculated that incorporate the costs of a proposed national training program and subsequent improvements in patient compliance. Sensitivity analyses are also conducted.ResultsBaseline assumptions suggest that the intervention would produce 2394 newly trained residents who could perform 71,820 additional colonoscopies or 119,700 additional flexible sigmoidoscopies after ten years. Despite high costs associated with the national training program, incremental cost-effectiveness ratios remain well below standard willingness-to-pay thresholds under base case assumptions. Interestingly, the status quo hierarchy of preferred screening strategies is disrupted by the proposed intervention.ConclusionsA national overhaul of family medicine residency programs offering training for colorectal cancer screening yields satisfactory incremental cost-effectiveness ratios. However, the model places high expectations on primary care physicians to improve current compliance levels in the US.     

Predictors and correlates of prevention research careers: a national study of residency graduates

BACKGROUND: Factors associated with research productivity among residency graduates are not well understood. The objectives of this study are to describe research productivity among preventive medicine residency (PMR) graduates and to identify factors that are correlated with high levels of productivity. METHODS: A detailed survey was mailed to all (n = 1,070) graduates from U.S. PMRs between 1979 and 1989. Main outcome measures for this analysis were (1) 25% of the workweek or more research time and (2) 20 or more publications since training completion. RESULTS: A total of 797 completed surveys were received for a response rate of 75%. Among respondents, 33% devoted at least 25% of their time to research and 13% had 20 or more publications. Independent positive predictors (P < 0.05) based on education and training of high research productivity as measured by both outcomes included research self-motivation, training at the Centers for Disease Control and Prevention, and clinical board certification. Concurrent correlates of current high research productivity by both outcomes included employment by the federal government or academia and academic appointment. CONCLUSIONS: Factors associated with high research productivity could be utilized to improve the resident selection process and promote research careers. This could enhance research programs and education and promote the overall prevention research agenda.     

Graded exercise stress test training in family practice and internal medicine residencies

A mail survey of upper Midwest family practice and internal medicine residency program directors was performed to determine the prevalence and characteristics of exercise stress test training. Two mailings provided a 68% response rate for the 184 programs surveyed. Internal medicine programs were significantly more likely to offer exercise stress test training than family practice programs (57% vs 34%). Overall, an estimated 31% of family practice and internal medicine residency graduates are performing exercise stress tests in their practice. Programs provided an average of 7.3 hours of didactic instruction and 32.7 stress tests per resident. A minority (43%) had an established minimum number of exercise stress tests recommended for competency. Programs with and without exercise stress test training did not differ significantly with respect to age, size of program, or size of community. There were some interstate differences in the extent of exercise stress test training provided by family practice residency programs. Internal medicine programs were more likely to require a minimum number of treadmill tests. Otherwise there were few differences between family practice and internal medicine program instruction in exercise stress test training. Family practice program directors were more likely to believe that their residents should be taught this procedure and to include family physicians in their panel of instructors. Specific guidelines should be created to assure adequate stress test training for interested residents.     

Clinical pharmacists in family practice residency programs

A project was undertaken to determine the number, specific activities, and demographics of clinical pharmacists directly involved with residency programs in family practice. A survey was mailed to the directors of all 381 family practice residencies, with a request either to forward it to the participating pharmacist or to return the survey if a pharmacist did not directly participate in the teaching program. With two mailings, responses were received from 85.3% of the residencies, with 80 pharmacists completing surveys. While the involvement of pharmacists in family practice residencies was similar to that reported in a survey 9 years ago, academic appointments and funding, in whole or in part by a college of medicine, had increased. This increased involvement may represent an acknowledgment by medical educators in family practice of the value of pharmacists participating in residency programs.     

Education of preventive medicine residents: alcohol,tobacco, and other drug abuse

BACKGROUND: Generalist physicians' addiction training is inadequate, but general preventive medicine residency (PMR) programs have not been studied. We determined PMR programs' alcohol, tobacco, and other drug abuse (ATOD) training from 1995 to 2000 and identified barriers to this education. METHODS: Interviewer-administered telephone survey of program directors (PDs) of accredited PMR programs in the United States. RESULTS: We interviewed all 41 PMR PDs. While 78% of PMR PDs reported interest in increasing ATOD education, for 68% it was not a high educational priority. Tobacco ranked in the top third of preventive medicine topics by 58%, while alcohol and other drugs ranked in the bottom third by 48% and 52%, respectively. Twenty-two percent of programs required a clinical ATOD rotation, most commonly smoking-cessation clinics. Only 29% of PMR PDs felt that residents were well prepared in clinical aspects of ATOD, while 60% felt that residents were prepared in ATOD research and public health issues. The most commonly reported barriers to ATOD training were lack of resident interest and defined competencies (64% each); limited faculty time (59%); limited teaching time (54%); lack of available teaching materials (53%); and lack of faculty expertise (51%). CONCLUSIONS: While the majority of PMR PDs recognize the importance of incorporating teaching about addictions into training, much of the ATOD education in PMRs focuses on tobacco alone. Setting educational standards, defining competencies, investing in faculty development, and creating ATOD curricular modules are important next steps toward preparing preventive medicine physicians to effectively reduce the public health toll of addictions.     

Fetal alcohol syndrome: knowledge and attitudes of family medicine clerkship and residency directors

Fetal alcohol spectrum disorders (FASD) are the leading preventable causes of developmental disabilities with serious permanent consequences. Regardless of the increased awareness of fetal alcohol syndrome (FAS), 13% of women in the United States drink alcohol during pregnancy. Health care professionals do not routinely assess the frequency and quantity of alcohol use by their patients. This study examined the knowledge, skills, and practices of family medicine residency and clerkship directors and assessed the time devoted and format of FAS curricula in the programs. A self-administered anonymous survey was sent to the residency and clerkship directors (N = 571). Response rate of clerkship directors was 52% and residency directors 46%. Both groups showed high level of knowledge of FASD and of alcohol counseling practices for pregnant women. Although almost two thirds of the residency programs had FASD integrated in the curriculum, an equivalent fraction of predoctoral programs did not. More than half of the clerkship directors without FASD in their curriculum agreed that a need exists for its inclusion. These findings raise important medical education and policy issues and provide insight into the disparity in FASD content of curricula between predoctoral and family medicine residency programs in the United States. The role of physician counseling in primary prevention of FAS should continue to be stressed in predoctoral and residency education.     

Recruitment,Promotion, and Retention of Women in Academic Medicine: How Institutions Are Addressing Gender Disparities

ObjectiveGreater numbers of women in medicine have not resulted in more women achieving senior positions. Programs supporting the recruitment, promotion, and retention of women in academic medicine could help to achieve greater advancement of more women to leadership positions. Qualitative research was conducted to understand such programs at 23 institutions and, using the social ecological model, examine how they operate at the individual, interpersonal, institutional, academic community, and policy levels.MethodsTelephone interviews were conducted with faculty representatives (n = 44) of the Group on Women in Medicine and Science, Diversity and Inclusion, or senior leaders with knowledge on gender climate in 24 medical schools. Four trained interviewers conducted semistructured interviews that addressed faculty perceptions of gender equity and advancement, which were audiotaped and transcribed. The data were categorized into three content areas—recruitment, promotion, and retention—and coded a priori for each area based on their social ecological level of operation.FindingsParticipants from nearly 40% of the institutions reported no special programs for recruiting, promoting, or retaining women, largely describing such programming as unnecessary. Existing programs primarily targeted the individual and interpersonal levels simultaneously, via training, mentoring, and networking, or the institutional level, via search committee trainings, child and elder care, and spousal hiring programs. Lesser effort at the academic community and policy levels were described.ConclusionsOur findings demonstrate that many U.S. medical schools have no programs supporting gender equity among medical faculty. Existing programs primarily target the individual or interpersonal level of the social ecological interaction. The academic community and broader policy environment require greater focus as levels with little attention to advancing women's careers. Universal multilevel efforts are needed to more effectively advance the careers of medical women faculty and support gender equity.     

Entry of US medical school graduates into family medicine residencies: 2010-2011 and 3-year summary

This is the 30th report prepared by the American Academy of Family Physicians (AAFP) on the percentage of each US medical school's graduates entering family medicine residency programs. This retrospective analysis based on data reported to the AAFP from medical schools and family medicine residency programs shows approximately 8.0% of the 17,081 graduates of US medical schools between July 2009 and June 2010 were first-year family medicine residents in 2010, compared to 7.5% in 2009 and 8.2% in 2008. Medical school graduates from publicly funded medical schools were more likely to be first-year family medicine residents in October 2010 than were residents from privately funded schools (9.6% versus 5.4%). The Mountain and West North Central regions reported the highest percentage of medical school graduates who were first-year residents in family medicine programs in October 2010 (14.3% and 11.3%, respectively); the New England and Middle Atlantic regions reported the lowest percentages (5.6% and 5.3%, respectively). Approximately four in 10 of the medical school graduates (40.3%) entering a family medicine residency program as first-year residents entered a program in the same state where they graduated from medical school. The percentages for each medical school have varied substantially from year to year since the AAFP began reporting this information. This article reports the 3-year average percentage from each medical school of graduates entering family medicine residencies and the number and percentage of graduates from colleges of osteopathic medicine who entered Accreditation Council for Graduate Medical Education-accredited family medicine residency programs in 2010.     

Core competencies for preventive medicine residents: Version 2.0

During the early 1990s, the American College of Preventive Medicine (ACPM), with support from the Health Resources and Services Administration (HRSA), identified core competencies and performance indicators (measures to assess their achievement) for all preventive medicine residents. After the competencies were approved, distributed by the ACPM and HRSA, and published in the American Journal of Preventive Medicine, they were integrated in various ways into the operation of individual residency programs. Changes in the health care system during the decade, however, necessitated an update of the original competencies to better equip preventive medicine educators to prepare residents for new roles those in preventive medicine can play in a restructured health care system. HRSA funded an effort to produce Version 2.0 of the preventive medicine competencies based on review and refinement of the original competencies through a consensus process. This article includes these revised core competencies and performance indicators.