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6. Infusion of New Fields into Medical Education
Pages 148-174

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From page 148...
... More recently, attention has been called to the need to educate physicians in such areas as health promotion, aging, behavior and health, nutrition, health policy, costs of health care, and legal and ethical issues in medical decision making. Undoubtedly, in the next few decades other significant areas will emerge or be recognized.
From page 149...
... behavioral sciences in medical education; and (3) health promotion and disease prevention in medical education.
From page 150...
... (In addition, drug-induced illness mimics the stereotype of old age -- absentmindedness, apathy, confusion, tremor, anorexia, and anxiety.) Finally, physicians often are the gatekeepers for community health and social services, including rehabilitation centers, day hospitals, hospices, housekeeping and home health services, in addition to acute care hospitals and skilled nursing facilities.
From page 151...
... Steering Committee on Undergraduate Medical Education Preparation for Improved Geriatric Carel° suggested the following responsibilities for medical schools: o to provide a focus for increased attention to aging; to establish a faculty group interested in gerontology and geriatrics ; o to expand research in aging; and 0 to offer a variety of clinical settings in which students experience the care , diagnosis, and treatment of the elderly ; to have medical students interact with healthy, independent elderly persons. Recent Trends in Education on Aging Medical School One of the early attempts to assess aging in medical school curricula was a review of 99 medical school catalogs for 1969.11 "Geriatrics," "gerontology," "senescence," "senility," or "aging" appeared in 124 course descriptions of 48 schools.
From page 152...
... 2.- The University of Florida uses the primary care program as a basis for teaching geriatric medicine. Emphasis is placed on ambulatory care, the incorporation of other professionals in the health care team, the use of community resources, and reliance on behavioral sciences to facilitate adherence to treatment regimens.
From page 153...
... This could be accomplished in a variety of ways including a department, a division of a department, or an interdepartmental steering committee.4~18 With regard to clinical clerkships for advanced medical students, the IOM committee recommended training in multidisciplinary settings of care, with nursing, social work, and rehabilitative specialty staff, and where other specialist consultants are available. There should be experience in nursing homes and other long-term care facilities, and with home health programs and other alternatives to institutionalization.4 Graduate Medical Education In 1978, the TOM Committee on Aging .
From page 154...
... Barriers that remain include "ageism" , a knowledge base that is growing, but that remains descriptive to a great extent; an emphasis on high technology in teaching hospitals; academic recognition going most readily to narrow specialty research rather than to the interdisciplinary research appropriate to studies of aging; a relatively modest pool of research funds relative to other disciplines; and a reimbursement system this focuses on acute care and that is a non-system for long-term care. Behavioral Sciences in Medical Education Studies of the burden of illness in affluent, industrialized nations such as the Uni ted States and Canada document that the prof lie of illness, early death, and related long-term disability have major behavioral components.20 Patterns of behavior often referred to as lifestyle account for as much as 50 percent of mortality from the 10 leading causes of death in the United States.21 Behavioral factors such as heavy cigarette smoking, excessive use of alcohol, and high risk-taking are important in the etiology and pathogenesis of cardiovascular diseases, cancers, respiratory diseases, and accidents, for example.
From page 155...
... Furthermore, inadequate training in counseling skills is the rule rather than the exception, and inappropriate prescription of psychotropics appears to be widespread. Recent Trends in Education on the Behavioral Sciences For the most part, departments of psychiatry and behavioral science, staffed by psychiatrists, psychologists, social workers, and other behavioral scientists, have been responsible for helping medical students acquire insight into interview techniques, knowledge of the diagnosis and treatment of mental disorder, and an appreciation for the intimate interplay of behavior, soctocultural factors, and physical health.
From page 156...
... Resistance has begun to shift and at least some consensus for change is appearing to develop. Most medical schools include behavioral science content in their educational programs and some schools have divisions or even departments of behavioral sciences.
From page 157...
... interpersonal skills and organizational behavior. In general, the behavioral sciences and psychiatry content in the medical curriculum reflects or in some way resembles areas identified in the content outlines of the National Board Examination.25 Clinical Training Effective application of skills requires practical experience.
From page 158...
... One benefit of such experiences can be in recruiting -- from the ranks of physicians who participate in them -- faculty role models who can demonstrate in their practice the relevance of biobehavioral sciences. Barriers to Progress Ei senberg and Kleinman30 suggest that the key task for medicine is not to diminish the role of the biological sciences in the theory and practice of medicine but to supplement it with an equal application of 158
From page 159...
... In addition, serious questions have been raised periodically regarding the relevance of biobehavioral sciences to the actual range of activities conducted by model physician populations. Biobehavioral science principles will only be meaningful if they are presented to medical students as a normal part of the health care process and not as something extraordinary or peculiar.
From page 160...
... Using the department as a base, individual behavioral scientists could engage in research relevant to a broad range of questions in clinical medicine. How willing students are to incorporate behavioral science content into their repertoire depends, in part, on the attitude of faculty-both basic science and clinical.
From page 161...
... . In arriving at a recommendation for an appropriate strategy for transmitting content of the biobehavioral sciences in medical schools, a number of programs should be surveyed in an effort to devise a model program.
From page 162...
... , effecting some savings.36 However, the dollar balance is uncertain because success in health promotion and disease prevention means survival for more years, and probable greater accumulated use of the health care system. Health promotion and disease prevention are not totally unfamiliar areas of medical competence.
From page 163...
... Recent Trends in Education on Prevention and Promotion Medical School Two recent conferences have stressed the importance of training in and an orientation to health promotion and disease prevention as an integral part of the medical school experience . 32, 41 Many entering medical students want to pract ice a prevention-oriented, patient-centered kind of medicine.39 For example, during the past two years, the University of California branches at both San Francisco and Los Angeles have developed and introduced preventive medicine curricula at the instigation of the medical students themselves.42 The prevention field has its own basic sciences: epidemiology, biostatistics, some aspects of social and behavioral sciences, and analysis of health care delivery systems.
From page 164...
... Preventive Medicine Residency Programs Four areas of special concentration have developed within the preventive medicine specialty: aerospace medicine, general preventive medicine, occupational medicine, and, of longest standing, public health. Physicians can obtain certification from the American Board of Preventive Medicine (ABPM)
From page 165...
... In its 1980 survey of preventive medicine residency programs, the American College of Preventive Medicine identified 68 active U.S. programs in public health, general preventive medicine, and occupational health; these programs included clinical, academic, or field-year training, offering 652 resident positions.48 However, only 53 percent of the positions were occupied.
From page 166...
... 36 To overcome this historical lack of specificity, several attempts at developing preventive medicine curricula have been made.50 The range of possible medical school curricula changes that would incorporate more prevention material includes (1) giving more teaching time to departments of preventive medicine , ~ 2 ~ integrating prevention into teaching of other disciplines, and (3 ~ starting over.
From page 167...
... Meeting the costs of teaching in such ambulatory-care-based specialties as family medicine, general pediatrics, and others, remains a major dilemma. Costs of inpatient clerkships disappear into the total hospital bill and to date are covered by third-party payers; ambulatory care, which is expensive for hospitals to provide, is less often covered by public and private insurance.53 In 1979/80, principal sources of funds for a sample of general preventive medicine residency programs were university general funds (38.1 percent)
From page 168...
... Particularly in health promotion, and particularly in the behavioral area, prevention suffers from the lack of status and lack of specifics that at f lict the behavioral sciences generally. Summary and Recommendations on Promotion and Prevention Ma jar conclusions and recommendations on the teaching of heal th promotion and disease prevention are: 1.
From page 169...
... 5. No serious national educational effort will take place until the problem of reimbursement is resolved.
From page 170...
... AAMC Steering Committee Report, Undergraduate medical education preparation for improved geriatric care -- A guideline for curriculum assessment. In Reference #6.
From page 171...
... L., eds. Health and Behavior: Frontiers of Research in the Biobehavioral Sciences.
From page 172...
... E Teaching medical students about disease prevention and health promotion.
From page 173...
... W., eds. Directory of Preventive Medicine Residency Programs in the United States and Canada, 2nd ed.
From page 174...
... In Byrd, B A., ea., Charting Graduate Education in Preventive Medicine.


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