Integrative medical education: development and implementation of a comprehensive curriculum at the University of Arizona.

Dissatisfaction with the U.S. health care system is increasing despite impressive technologic advances. This dissatisfaction is one factor that has led patients to seek out complementary and alternative medicine (CAM) and led medical schools to start teaching CAM. This paper focuses on the University of Arizona's approach to developing and implementing a comprehensive curriculum in integrative medicine. Integrative medicine is defined much more broadly than CAM. It is healing-oriented medicine that reemphasizes the relationship between patient and physician, and integrates the best of complementary and alternative medicine with the best of conventional medicine. Since its inception in 1996, the Program in Integrative Medicine (PIM) has grown to include a two-year residential fellowship that educates four fellows each year, a distance learning associate fellowship that educates 50 physicians each year, medical student and resident rotations, continuing medical and professional education, an NIH-supported research department, and an active outreach program to facilitate the international development of integrative medicine. The paper describes the PIM curriculum, educational programs, clinical education, goals, and results. Future strategies for assessing competency and credentialing professionals are suggested.     

Matching community need with physician training: the OSU Urban Family Medicine Program

There continues to be a shortage of primary care physicians practicing within urban, Iower-socioeconomic and minority communities despite the fact that many of the 125 allopathic and 19 osteopathic medical schools are located within the affected urban cities. Recognizing a need to better train and recruit primary care physicians to serve in urban settings and provide care to those underserved. The Ohio State Department of Family Medicine established an Urban Family Medicine Residency Program headquartered in Near East Columbus, OH. Starting in 2003, the Urban Family Medicine Residency Program began training up to two residents each academic year. The mission, vision and (curriculum have attracted residency applicants and faculty who have displayed sincere interest and commitment to practicing in urban lower socioeconomic communities.     

Competency-based evaluation tools for integrative medicine training in family medicine residency: a pilot study

Background  

As more integrative medicine educational content is integrated into conventional family medicine teaching, the need for effective evaluation strategies grows. Through the Integrative Family Medicine program, a six site pilot program of a four year residency training model combining integrative medicine and family medicine training, we have developed and tested a set of competency-based evaluation tools to assess residents' skills in integrative medicine history-taking and treatment planning. This paper presents the results from the implementation of direct observation and treatment plan evaluation tools, as well as the results of two Objective Structured Clinical Examinations (OSCEs) developed for the program.     

Innovations in integrative health care education

The University of Arizona is justifiably famous for starting the first Program in Integrative Medicine Fellowship under the leadership of Dr. Andrew Weil several years ago. This was followed by creation of the successful distance learning Associate Fellowship. Now, making a potentially even broader contribution to the future of medicine is a new program, Integrative Family Medicine (IFM).     

Teaching the teachers: helping faculty in a family practice residency improve their informatics skills.

Faculty members in family practice residencies are increasingly being asked to help residents develop skills in the use of informatics and evidence-based medicine (EBM). In order to do this successfully the teachers themselves must be skilled in the use of these tools. Recognizing the need for such training, the Maine Medical Center Family Practice Residency Program designed a faculty development project to increase knowledge and skills in the use of information technology. This project, which was carried out in 1999-2001, utilized a multifaceted approach that included improving the residency's technology infrastructure, conducting two instructional workshops, and offering EBM mentoring for preceptors. Faculty members also designed and carried out independent informatics projects. Pre- and post-project assessments of faculty members demonstrated a significant improvement in computer and EBM skills, and informal feedback from residents indicates that these skills have been successfully applied to the faculty members' teaching of residents and their practice of family medicine. This project had a positive impact on the faculty members in the residency program, increasing both their ability to employ information technology in individual and group teaching sessions and their use of EBM in clinical practice. Also, the culture within the residency program has been changed to one of utilizing computers and the Internet as principal resources for up-to-date information.     

The development of a medical ethics curriculum in a General Internal Medicine Residency Program

Since 1984, a three-year curriculum in medical ethics has operated at Rhode Island Hospital as part of the General Internal Medicine Residency Program at the Rhode Island Hospital and Brown University. The residency program was founded in 1980 to develop a model training program for internal medicine residents with a primary care focus. The three objective of the curriculum are (1) to enable residents to recognize the ethical implications of both inpatient and outpatient clinical cases, (2) to teach residents to recognize ethics issues and alternatives in order to arrive at a well-rounded clinical strategy, and (3) to help them learn to communicate sensitively with patients and others about these ethics issues and proposed management plans. The six major topics covered by the curriculum (for example, informed consent) are co-taught in a seminar format by one or more of the three members of the multidisciplinary ethics faculty (a philosopher, an internist, and a communications specialist) and experienced physicians. The authors describe the program, the roles of the various faculty members, the program's focus on case discussions, the receptivity of the residents and faculty to the program, the use and training of a multidisciplinary faculty, efforts aimed at evaluation, and future directions of the program.     

Specialization in family medicine--has all the planned been achieved?

The planned, comprehensive inclusion of general practitioners/family physicians in specialist education has begun with the project entitled Harmonization of Family Medicine Service with European Standards by the Implementation of Compulsory Residency. According to the Project, all physicians working in family medicine practice should have an opportunity to complete the respective residency by 2015. Analysis of the planned and completed family medicine residency in Croatia during the 2002-2006 period is presented. Of the total family medicine residency positions planned during the four-year period, 543 (90.5%) have been completed, with the greatest discrepancy recorded in program A applying to physicians younger than 35 having concluded a contract with the Croatian Institute of Health Insurance. In addition, this relationship varied among different countries. There are a number of obstacles hindering the Project implementation. However, it should be noted that the Project has made a breakthrough in upgrading the quality of family medicine practice, as a pledge of future development and rational performance of the entire health care system in Croatia, in order to promote the health care of the population at large.     

A novel approach to training pediatrics primary care residents

From 1984 through 1987, 12 pediatrics residents from the Yale University School of Medicine took part in a three-year program that emphasized four areas in primary care: well-child care, developmental-behavioral pediatrics, chronic illness, and adolescent medicine. Program evaluation included a videotaped interview, an assessment of the residents' skill in the management of patients' behavioral problems, and multiple-choice examinations. The program residents improved their interviewing skills more than did the comparison residents, particularly in the process and psychosocial content areas, and also did better in the management of patients' behavioral problems. There was no difference in factual knowledge of behavioral and developmental pediatrics and adolescent medicine. While traditional residency training in primary care may provide the resident with comparable cognitive knowledge, such training may not always improve the resident's ability to apply the knowledge in the primary care setting.     

Benchmarks of support in internal medicine residency training programs.

PURPOSE: To identify benchmarks of financial and staff support in internal medicine residency training programs and their correlation with indicators of quality. METHOD: A survey instrument to determine characteristics of support of residency training programs was mailed to each member program of the Association of Program Directors of Internal Medicine. Results were correlated with the three-year running average of the pass rates on the American Board of Internal Medicine certifying examination using bivariate and multivariate analyses. RESULTS: Of 394 surveys, 287 (73%) were completed: 74% of respondents were program directors and 20% were both chair and program director. The mean duration as program director was 7.5 years (median = 5), but it was significantly lower for women than for men (4.9 versus 8.1; p =.001). Respondents spent 62% of their time in educational and administrative duties, 30% in clinical activities, 5% in research, and 2% in other activities. Most chief residents were PGY4s, with 72% receiving compensation additional to base salary. On average, there was one associate program director for every 33 residents, one chief resident for every 27 residents, and one staff person for every 21 residents. Most programs provided trainees with incremental educational stipends, meals while oncall, travel and meeting expenses, and parking. Support from pharmaceutical companies was used for meals, books, and meeting expenses. Almost all programs provided meals for applicants, with 15% providing travel allowances and 37% providing lodging. The programs' board pass rates significantly correlated with the numbers of faculty fulltime equivalents (FTEs), the numbers of resident FTEs per office staff FTEs, and the numbers of categorical and preliminary applications received and ranked by the programs in 1998 and 1999. Regression analyses demonstrated three independent predictors of the programs' board pass rates: number of faculty (a positive predictor), percentage of clinical work performed by the program director (a negative predictor), and financial support from pharmaceutical companies (also a negative predictor). CONCLUSIONS: These results identify benchmarks of financial and staff support provided to internal medicine residency programs. Some of these benchmarks are correlated with board pass rate, an accepted indicator of quality in residency training. Program directors and chairs can use this information to identify areas that may benefit from enhanced financial and administrative support.     

The availability of fellowship training for foreign family physicians

The authors surveyed the 49 U.S. fellowship programs in family medicine listed in the 1988 Fellowship Directory published by the Society of Teachers of Family Medicine. The past experience and future intentions of the 47 responding programs toward non-immigrant foreign family physicians coming to the United States to undergo fellowship training in academic family practice were studied. Only a minority of the programs (22%) had ever trained a foreign fellow, and of these only five of 11 were definitely able to do so in the future. Over half (52%) of the programs that had never trained a foreign fellow stated that they were not prepared to train a foreign physician. Although foreign family physicians are encouraged by the American Academy of Family Practice to come to the United States for fellowships, this study shows that it is extremely difficult for these physicians to find programs willing to act as host.     

Psychosocial training in U.S. internal medicine and family practice residency programs.

PURPOSE: Competence in the psychosocial aspects of medical care is necessary for primary care physicians to function effectively. This study investigated the psychosocial training internal medicine and family practice residents receive in U.S. programs. METHODS: In 1996, program directors of all U.S. internal medicine (IM) and family practice (FP) residency programs were surveyed regarding the format, content, and quantity of psychosocial training provided in their programs, their opinions on topics related to psychosocial training, and demographics of their programs. RESULTS: The response rate was 61%. Ninety-nine percent of FP and 62% of IM program directors reported requiring at least one psychosocial training experience. Family practice programs required an average of 352 hours (SD +/- 175; range 27-2,664) of psychosocial training compared with 118 hours (SD +/- 272; range 0-1,050) for IM programs. Most IM and FP program directors expected residents to achieve at least basic competency in virtually all psychosocial topic areas; however, FP programs provided a greater range of psychosocial experiences. FP program directors most often identified psychologists and IM program directors most often identified internists as providing the most psychosocial training in their programs. Both IM and FP program directors considered lack of curricular time to be the main obstacle to development of psychosocial training. CONCLUSION: Residents' competence in psychosocial areas is important to both IM and FP program directors. However, content and time devoted to psychosocial training vary considerably both within and between program types.     

A program of management training for residents

To help prepare residents in preventive medicine and occupational medicine for their future management roles, the University of Arizona College of Medicine incorporated administrative training into many aspects of its residency programs, beginning in 1983. Training focuses on seven skill areas seen as needed to meet the management demands of the physicians' future specialties. The authors discuss the career choices of University of Arizona graduates and advocate long-term administrative training for all specialties.     

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.     

Challenges and opportunities in the application process for fellowship training in pathology: an independent survey of residents and fellows demonstrates limited interest in an NRMP-style matching program

A survey completed by 366 pathology residents and fellows examined preferences for 3 fellowship application systems: keeping the current system, a National Resident Matching Program (NRMP)-style match, and a unified time line. All groups showed a strong preference for a time line, accounting for 62.1% of first choices vs the current system (17.3%) or a match (20.6%). When asked for a second choice after time line was ranked first, 60.5% of respondents whose fellowship of choice was available at their residency institution and 63.5% who had accepted fellowship positions at their residency institution preferred the current system; 51.4% whose fellowship of choice was not available at their residency institution and 50.6% of those who had accepted fellowship positions elsewhere preferred a match. Location and family/personal reasons were more important than subspecialty competitiveness and program prestige when accepting fellowship positions. Pressure to choose and apply early for fellowship persists and is greatest for anatomic pathology-only and clinical pathology-only residents.     

Teaching medical ethics during residency

Because practicing physicians are poorly prepared to resolve many ethical issues that arise in patient care, this article proposes that residencies include practical training in medical ethics. Training in medical ethics helps physicians recognize ethical issues in patient care and resolve those issues wisely. Furthermore, such training has its maximum impact during the professionally formative years of residency. The article specifies key ethical concepts residents should know, including knowing how to obtain informed consent, knowing what to do about incompetent patients, knowing when to withhold or disclose clinical information, and knowing how to use resources properly. The article also points out that the success of residency training in ethics depends on strong commitments from the department: endorsement by the chairman and the residency program director; recruitment of several dedicated faculty; support for adequate ethics training for these faculty; dedication of conferences, rounds, and consultations to teaching ethics; and allocation of sufficient funds.     

A successful combination

In 1967, the American Board of Pediatrics and the American Board of Internal Medicine uniformly recognized the 4-year combined medicine and pediatrics training program. Since that time, the number of combined internal medicine and pediatrics programs has increased. Today, there are more than 78 combined residency programs with more than 354 first-year residency positions throughout the United States. Medicine/pediatrics residency programs give the resident the opportunity to rotate 24 months in each specialty. Graduates of combined medicine/pediatrics residency programs have several career options available to them. In 2007, a total of 55% of medicine/pediatrics residents went into primary care practice, 18% went into subspecialty training, 17% went into hospital medicine, and 10% chose other careers.     

The preferred learning style among residents and faculty members of an internal medicine residency program

OBJECTIVE: To determine the preferred learning style, as defined by David Kolb, and predictors of the different learning styles among residents and faculty members at an internal medicine residency program. DESIGN/SETTING: A cross sectional study of internal medicine residents and faculty members at Morehouse School of Medicine was performed using the Kolb Learning Style Inventory (LSI) version 3.1. MEASUREMENTS: The Kolb LSI is a questionnaire of 12 sentences, each with four phrases for sentence completion that are to be ranked according to how they apply to the subject. RESULTS: Forty-two out of 59 questionnaires that were given out to residents and attending physicians were properly completed and returned. Assimilating style was the predominant learning style among residents (42%) and attending physicians (55%). There was no significant association between age, gender or medical education status, and learning styles. CONCLUSIONS: The understanding of residents' learning styles may facilitate instructional rapport between residents and attending physicians, thereby improving residents' academic performance.     

Evaluation of a program to train Saudi Arabian physicians

The authors evaluated a program at the University of Calgary, in Alberta, Canada, that provided residency training for 11 Saudi Arabian physicians. Through a series of semistructured meetings in 1989 involving the Saudi residents, other residents in the program, members of residency training committees, faculty, and program directors, the program was reviewed to assess whether the Saudi physicians were prepared for the program and progressed satisfactorily when compared with the other residents, whether the training and evaluation were equivalent to those of the other residents, the advantages of the program to the university, and whether the university should be pursuing opportunities to train other foreign nationals. The interviews showed that there was variability in the preparation and progress made by the Saudi residents but the benefits to the university in providing training to a small group of carefully selected foreign-trained physicians were greater than the disadvantages. The information gained during the review reinforced the need to do periodic examinations of training opportunities for foreign physicians and yielded recommendations for improving such training.     

A systematic approach to faculty development in Women's health: lessons from education, feminism, and conflict theory.

The authors present a strategy for residency faculty development in women's health, the reasons that such a strategy is necessary (e.g., women's health encompasses much more than reproductive and disease issues, and is cross-disciplinary and intrinsic to all of family practice), and their residency program's experience with its development and implementation from 1994 to the present. In creating the program, the residency program's faculty used as a context some lessons learned from family medicine, since the rapid growth of family medicine provides a historical example of dealing with a critical shortage of faculty for new residency programs and the need for a new way to train educators. Also, the faculty reviewed the literature about faculty development in medicine, models of teaching and learning from women's studies, and group theory, specifically the skills concerning conflict and diversity. They used the salient elements from each (which the authors outline) in fashioning their new faculty development program. The resulting program also grew out of focus groups with patients, input from staff, residents, and faculty, and meetings and workshops, including some intense and highly charged discussions in which the faculty participants, both men and women, confronted their own views and biases and worked hard to successfully forge a common and relevant vision of women's health. The program has fostered faculty who are knowledgeable about the diverse educational skills required to teach women's health. They use these skills in all curricular content, thus demonstrating a new way to educate residents as well as faculty.