Community Oriented Primary Care New Directions for Health Services Delivery (1983) / Chapter Skim
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Medical Education and Training for Community Oriented Primary Care
Medical Education and Training for Community Oriented Primary Care
Pages 167-197
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From page 167... ...
Population-based medicine (community medicine, public health, social medicine) has continued to grow further away from the mainstream of curatively oriented, high-technology biomedicine in both training and in practice.
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From page 168... ...
Fulop3 supports the notion that forms of practice are the deciding variable: "medical doctors as well as other health workers tend to adapt to the existing health system even when they have been trained for different tasks and circumstances. It is, therefore, in the health system that change, or at least careful plans for change are first required, then in the training of personnel for those systems." Funkenstein9 in his National Representative Sample study of medical students between 1958 and 1976 shoots holes in the alleged power of the "role model," at least in undergraduate medical education: "One of the most cherished ideas of the faculty has been their influence as role models on the career choices
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From page 169... ...
The extensive review of a vast literature on the influence of medical education on medical practice conducted for the report of the Graduate Medical Education National Advisory Committee (GMENAC) Technical Panel on the Educational Environmenti° revealed three important factors: 1.
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From page 170... ...
MEDICAL EDUCATION AND COPC In addition to role models, practice environments, and institutional/societal influences, there is a fourth factor that likely influences student behavior and later practice forms. That factor is the specific content areas or educational experiences of undergraduate and graduate medical students.
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From page 171... ...
training experiences in the principles and skills of"community medicine." PRIMARY CARE EXPERIENCES UNDERGRADUATE For the purpose of this review, primary care is defined as first contact care that is comprehensive (promotive, preventive, curative, rehabilitative) , coordinated, and provides continuity of relationship between patient and physician.
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From page 172... ...
Several types of perceptorships have been implemented and documented. In one type the majority of the student's time is spent in the clinical setting with a physician and the other time is variably scheduled for a seminar on community health issues, a placement in a community health agency, or work on a community health project.
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From page 173... ...
The Beersheva Experiment in Israel23 and University of New Mexico Primary Care Curriculum24 did likewise build an entire medical education program around the needs for primary care in a given area. Thus, with notable exceptions involving major curriculum revision, preceptorship programs have generally been the most common vehicle for the introduction of primary care in the community tO undergraduate medical students in the United States.
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From page 174... ...
Donsky and Massad26 conducted a survey of 122 family practice residency programs in 1978 to determine the extent to which formal concepts of community medicine were taught. In the introduction to their study, they point out that the accreditation requirements for family practice residencies indicate that "principles of epidemiology should be taught; community medicine should provide the resident with an approach to the evaluation of the health problems and needs of a community and to the improvement of
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From page 175... ...
The authors concluded that "community medicine" is taught more often as context than as a set of skills to be learned by an effective practitioner. In 1979 Rosinski reported on his study of the 13 residency programs in primary care internal medicine and pediatrics funded by the Robert Wood Johnson Foundation.
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From page 176... ...
Werblun describes a similar evolution towards a more structured curriculum in community medicine in the University of Washington family practice residency program.29 To meet a perceived need for primary care physicians with community medicine or primary care research skills, a small number of primary care residency programs in pediatrics, medicine, and family practice have begun to offer joint residency training in both a primary care specialty and in preventive medicine. For example, the University of Utah has a joint program in family medicine and preventive medicine.
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From page 177... ...
Medical students turned towards the community for "relevance" and an opportunity for"service." Clinical faculty were largely uninvolved in this trend and certainly avoided itS incorporation into core medical education offerings. Rather, faculty rationalized medical school activity in the community because it was a "living laboratory for research,"30 a laboratory in which the medical school studies certain problems."3i The mission of the medical school in the community was thus defined by one segment of the academic community the students as a"service" and by the other—faculty "research." Because of the nature of the times in which these positions were drawn and the political turmoil that often characterized the involvement of medical schools in the delivery of health services in or to "the community" during the 1960s, the development of community-based or community oriented medical education activities has remained controversial and thus problematic.
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From page 178... ...
In many medical schools, student enthusiasm for "service opportunities" and the desire of community medicine faculty to avoid the stereotyped rigidity of traditional medical school faculty probably contributed to community medicine being seen as without discipline, representing an attitudinal, contextual learning rather than a set of skills to be learned, practiced, and integrated into clinical medicine. In the 1970s the student projects changed as the American Medical Student Association (AMSA)
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From page 179... ...
Most faculty remain inexperienced in design and implementation of organized experiential learning activities outside school walls, especially those integrating clinical and community medicine. TRAINING IN PRINCIPLES AND SKIMS OF COMMUNITY MEDICINE There were and are some notable exceptions to the experiential, sensitizing focus of"community oriented" educational experiences in community medicine.
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From page 180... ...
Bennett describes the evolution of his approach tO community medicine training of medical students and community health workers in Africa over the past 20 years.36 Using an interdisciplinary faculty (biomedical, community medicine, and clinical) in "teaching health centers" and "teaching health districts," students assume progressively more responsibility for design and implementation of community diagnosis in conjunction with the community and other health workers.
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From page 181... ...
The clarity of goals, role definition, and appreciation of the resources other disciplines may bring to a particular health care task all critical to a well-functioning team—are highly variable. The need for a team approach to the teaching and practice of COPC is evident and, in my opinion, the educational methods and technology for team practice are well tested and just waiting to be applied in COPC programs.43~45 The need to integrate the teaching of these different elements of COPC has been articulated in several national reports, including A Manpower Policy for Primary Health Care issued by the Institute of Medicine in May 1978~7 and a report on the National Rural Practice Project sponsored by the Robert Wood Johnson Foundation in support of"community responsive practice."46 STRATEGIES FOR MEDICAL EDUCATION AND TRAINING FOR COPC I think the evidence is compelling that there are at least four strategies that can be effective in education and training for COPC: .
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From page 182... ...
This group of faculty are uniquely open to colleagueship with community medicine faculty and tO the inclusion of systematic principles of community medicine such a those espoused in COPC as an integral part of primary care training and practice. Community medicine faculty are increasingly involved in health services research.
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From page 183... ...
Grant programs should encourage the collaboration of departments of community medicine, schools of public health, or their analogues with primary care residencies and clinical departments sponsoring primary care clerkships. Such efforts should include faculty development programs in which faculty are trained in COPC (using models like the training workshops of Kark and others)
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From page 184... ...
COPC as defined by Kark, is a uniquely appropriate vehicle to end the polarization between segments of the academic community over community-based education. The integration of community medicine skills into primary care practice expands the ability of the clinical practitioner tO provide service tO the community (users and nonusers)
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From page 185... ...
It has not yet extended to COPC, but as Sidney Kark said, "the community cannot demand what it does not yet know and has not yet experienced." Any observer of the current cutbacks in health services in neighborhood health centers has noted the increased dissatisfaction of patients who object to declining social, mental health, and outreach services they learned tO expect in the 1960s. Patients of private practitioners are increasingly assertive about their rights to certain services and information from their physician.
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From page 186... ...
The enthusiasm of students for primary care has really driven the machinery initially set in place by foundation and federal support for educational model-building in primary care. The fact that 10 percent of the student body of a certain biomedically oriented medical school elected family practice residencies when that school has no family medicine department, division, or teaching program is a sign of the will of students that can override faculty and institutional intent.
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From page 187... ...
Training Community Health Workers, 1966-1974. 3674 Third Avenue, Bronx, NY 10456.
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From page 188... ...
(1968) The Student Health Project: A New Approach to Education in Community Medicine.
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From page 189... ...
(1973) Community Medicine and Primary Health Care: A Field Workshop on the Use of Epidemiology in Practice.
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From page 190... ...
I bring with me considerable baggage that biases my view as a dean. I have been a chairman of a department of community medicine, I was involved with the Watts Community Health Center, and I have participated in the reorganization of the Los Angeles County Health Services Department from three separate departments to one significant whole, which was probably one of the more unnoticed but greatest ventures in recent times.
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From page 191... ...
We have a manpower shortage in role models and in teachers. The accrediting agencies for the primary care programs have concentrated so much on process and staff characteristics of primary care programs that energy has been diverted from the essential task of defining the congnitive values of those specialties in understandable and achievable terms.
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From page 192... ...
First, we have a powerful ally in that progress in health sciences has brought the personal and community health concerns together as the heart of a viable health care practice mode. Until recent years the primary concern
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From page 193... ...
Today, the most dramatic issues of community medicine affect rich and poor alike. Properly exploited, this reality should enhance the chances of adequate funding for community oriented concerns of COPC.
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From page 194... ...
Dr. Boufford has identified a number of critical components and categories of preparatory experience for community oriented primary care.
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From page 195... ...
Dr. Boufford has alluded to community role models as an important factor in education for community oriented primary care, and I agree wholeheartedly and have served from time to time in this capacity for student or resident preceptees from the University of New Mexico.
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From page 196... ...
We have seen examples all around us of community oriented health professionals who participated vigorously during the 1960s in student projects. The approach works.
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From page 197... ...
Frankly, if we are not practicing, promoting, teaching, or funding the elements of community oriented primary care, what are we waiting for? The alternatives will be wasteful for society, probably transient, and, in my opinion, a lot less fun.
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