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OCR for page 167
Medico Eclucation and
Training for Community
Orientecl Primary Care
Jo They Boaffordf
In the opening chapter of his book Commz~r~ity-Oriented Primary Health
Care, Sidney Kark systematically provides definitions for and distinctions
between "primary care," "public health," and "community medicine." The
clarity of Kark's distinctions makes it possible to understand the importance
of their integration into the concept of community oriented primary care
(COPC), the focus for this conference..Jack Geiger has noted that the
integration or synthesis of a variety of familiar features of health care into
a unifying, action-oriented program is the uniqueness of COPC.i The tra-
dition in American medicine and health professions education has been to
keep these approaches to health care separate. 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. The debate between invest-
ment in the "personal encounter system" of care versus the "public health
system" of care is well laid out in McDermott's paper "Medicine: The Public
Good and One's Own"2 and is familiar to all of us. This polarization has
characterized the American approach to solving the problems of providing
health care for its people. In order to accept COPC, a conceptual shift is
required in most of our thinking. Such a shift would allow for the synthesis
of ideas and programs that tend to be portrayed as antithetical and whose
proponents and practitioners often appear to be competing with one an-
other. To be truly effective, this synthesis that is COPC must take place
in the clinical practice setting that will present a challenge to both educators
167
OCR for page 168
168
PART I: THEORETICAL ISSUES
and practitioners. It is the purpose of this paper to examine the implications
of COPC for medical education and training.
MEDICAL EDUCATION AND MEDICAL PRACTICE
Three main components of the health manpower development process have
been identified by Fulop3: planning, development (education and training),
and management (in the work environment). He and many others feel that,
ideally, each of these steps should be integrated into a single process. This
is sometimes referred to as "controlling both ends of the pipeline." Those
responsible for planning the health care delivery system also exert control
over the training process to assure that those health personnel who will
enter the delivery system are appropriately prepared tO perform the job
that is required of them. This approach has often been the guiding principle
behind the development of"new health roles," especially in developing
countries with a dearth of"health professionals"—doctors, nurses, dentists,
pharmacists, etc.4 5 6 It was also the general approach used in the training
of new health workers during the OEO period of support for the devel-
opment of neighborhood health centers in the United States.78 In this
approach, the needs of a population or community are identified, and
individuals, often members of that community, are specifically trained to
perform the needed role.
In some systems of state medicine, the Ministry of Health or its equivalent
controls the apparatus for education of the various health professionals.
The numbers and types of physicians, nurses, and others can be regulated
and, often, their practice location predetermined according to health system
needs. This continuity of planning, development, and management has
certainly not been the pattern worldwide, especially for the profession of
medicine. It is interesting to speculate about what influence physician ed-
ucation and training has on later practice when the control of education
and practice are not coordinated, as in the United States.
There are clearly two schools of thought. One holds that there is little
connection between education and practice. 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
OCR for page 169
Medical Education and Training
169
of their students. No data were found to support this. In none of the years
of studying ... students, did more than 18~ of the students feel that
anyone of the faculty had influenced their choice of career." Funkenstein
attributes the greatest power to influence student career choice to economic
incentives and ideology (or the societal value of the time). He feels that
both must be present and congruent to influence the student toward a
particular and societally favored career; otherwise students are likely to
follow their basic characteristics, either the "bioscientif~c" or the "biosocial,"
each leading them in different directions. He sees the trends of the late
1970s towards primary care and family medicine in the United States as
related to government action, economic viability, the ideology of the times,
the decrease in funding for academic medicine, and the perceived excess
in the number of specialists and surgeons.
Based on these kinds of findings, I should probably end this paper here
and we should all go OUt and set up some COPC practice models with a
good program of in-service education for all who would work there! Yet,
being involved in medical education, I am not willing to write off its influ-
ence on the career choices of physicians, nor its potential to facilitate the
implementation of COPC.
There is considerable evidence elsewhere in the medical education lit-
erature that something is happening to large numbers of students as they
pass through the educational process. The extensive review of a vast lit-
erature on the influence of medical education on medical practice conducted
for the report of the Graduate Medical Education National Advisory Com-
mittee (GMENAC) Technical Panel on the Educational Environmenti°
revealed three important factors:
1. Faculty role models can be influential in "passing on values and atti-
tudes that can have long-term impact."
2. The student's ability tO "role play" or test and practice newly acquired
knowledge, skills, values, and attitudes is important to professional shap-
ing.3911
3. Institutional influences, at least the allocation of program resources,
determine the power of f~rst-order influences (role models and role playing
opportunities). if
Availability of funds and the social climate in turn shape these "institu-
tional influences." Prior tO the impetus of the 1972 Health Professions
Education Assistance Act to promote selection of primary care specialty
choice and location in medically underserved areas, students were clearly
choosing careers in the surgical and nonsurgical subspecialties over those
in primary care. While recent figures seem tO indicate that more than 60
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170
PART I: THEORETICAL ISSUES
percent of first-year residency positions are now being selected in primary
care disciplines, it is not clear that this trend will continue. In fact, a recent
article in the New England journal of Medicine suggests that gains made in
primary care from 1970 to 1975 may not be holding up over the period
1975-1980.~2 This may reflect a decrease in the "ideology factor" proposed
by Funkenstein, as federal funds to support institutional initiatives in this
direction have been declining.
Graduate medical education, on the other hand, is a less studied period
of education intervention. The data to date would seem to indicate that it
may be the most fruitful and influential period for exposure to models that
influence medical practice. Studies by Wilson and her colleaguesi3 of former
National Health Service Corps (NHSC) and non-NHSC physicians prac-
ticing in primary care specialties in underserved areas (mostly rural) show
that, while personal background characteristics of the individual are the
strongest factors in practice location and specialty choice, those locating in
shortage areas tend to have perceived faculty in their residency programs
to be more supportive of shortage area practice; they are also more likely
to have done their residency in a clinic or health care facility in a similar
area tO the one in which they are practicing be it low-income and/or un-
derserved, both rural and urban. Hadleyi4 also shows a high correlation
between site of residency and ultimate practice location. The overall ex-
perience in the field of family practice since 1969 has clearly demonstrated
the trend of family physician graduates entering communities of 30,000 or
less population that have previously been without a physician.~5
The implications of these kinds of findings can be summarized in the
following way. People do not voluntarily subject themselves to experiences
for which they feel unprepared. Exposure during education and training,
especially graduate training, to the forms and locations of practice and to
individual practitioners that support the implementation of desired practice
forms (COPC for example) will, at the very least, demonstrate options to
individuals who would otherwise never be exposed to them and, at best,
significantly shape how individuals in these programs will practice in the
future.
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 edu-
cational experiences of undergraduate and graduate medical students. If we
examine medical education, there has been a history of efforts to introduce
the components of COPC into U.S. medical education and into medical
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Medical Education and Training
171
education abroad. In reviewing these efforts, the obstacles tO an integrated
presentation of COPC in the current models for medical education in the
United States become clearer. Recognizing these obstacles, strategies can
be suggested for educational change to facilitate and promote COPC prac-
tice.
Briefly, the critical components of a COPC practice are:
. the provision of primary care services;
and
. a focus on the community as a whole in assessing needs, planning and
providing services, and evaluating the effects of care;
a community-based activity;
. involvement of the community in the promotion of its own health;
. the team approach.
Each of these program components implies a constellation of skills to be
learned by the future practitioner. A variety of efforts have been made to
provide educational experiences for medical students and residents in one
or a combination of these skills. Though there are very few educational
programs, probably none in the U.S. that represent the total integration of
COPC components, the experiences that have been offered could be char-
acterized under three general headings:
. primary care experiences (undergraduate and graduate);
. community "oriented" educational experiences; and
. training experiences in the principles and skills of"community medi-
cine."
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), co-
ordinated, and provides continuity of relationship between patient and phy-
sician. This is the definition originally proposed by Alpert and Charney in
1974.~6 The Institute of Medicine in its report "Primary Care in Medicine:
A Definition" adds the concepts of accessibility (in time and location) and
accountability of services rendered by a team. i7 These additions are certainly
. . .
consistent wit ~ our intent.
Primary care educational experiences are found throughout the under-
graduate and graduate medical education experience in the United States.
The major impetus for the development of these programs has been the
support of federal funds under the various Health Manpower Development
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172
PART I: THEORETICAL ISSUES
and Training Acts beginning in 1972. The major vehicle for undergraduate
primary care exposure has been the "preceptorship." The definition of a
preceptorship used by DHHS to guide its program support efforts is "at
least two weeks continuously under the supervision of a physician preceptor
in the practice of primary care outside the academic medical center." In
a survey of 95 medical schools conducted as part of itS preceptorship pro-
gram evaluation activities, DHHS determined that in 1976-1977, of 92
medical schools responding, all but 1 indicated that they had a preceptorship
program that met this definition, and 73 of 137 such preceptorship programs
were federally funded. The federally supported programs were more likely
to emphasize primary care, preventive medicine, and location in under-
served areas than those sponsored solely by the medical school. Overall
program evaluation indicated that student satisfaction was directly related
to the amount of "desired hands-on experience that was actually received"
and that more than 50 percent of students felt that such an educational
experience assisted in clarifying their preference for a specialty, size of
community, and form of practice. Seventy percent of students selecting
family medicine had had one or more preceptorship experiences, but this
correlation was felt to represent student self-selection rather than the fact
that the preceptorship was a critical incident in specialty or location choice.
In addition, the effective structural variables in the preceptorship could not
be identified.
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. Morrisoni9 describes such an expe-
rience for a psychiatry clerkship. Since 1979, the American Medical Student
Association (AMSA) has run a preceptorship program for National Health
Service Corps scholarship recipients on behalf of the Corps. Medical and
dental students are placed for 4-8 weeks with NHSC physicians in Corps
practice sites in health manpower shortage areas. Most students are at the
clinical level and the majority of their time is spent in preceptorship rela-
tionships with the NHSC physicians in their clinical practice. They are also
assigned a small community project, usually clinically related, performing
tasks such as developing health education materials or organizing a screening
program. Preclinical student placements involve "shadowing" the clinician
and a larger-scale project effort often involving community assessment. The
goals for these preceptorships are acclimation of the scholarship recipient
to the underserved setting and exposure to a primary care physician role
model. More than 800 students have been placed in the past 2 years.
Buttery and Moser20 describe a combined community and family med-
icine clerkship in which 5 half-days per week are spent in the physician's
OCR for page 173
Medical Education and Training
173
office, 2 half-days in a structured seminar on the epidemiology of three
clinical entities, 1 half-day in the ER, and 1 half-day in a public health
agency. While the clinical portion of this preceptorship was evaluated ac-
cording to traditional performance parameters, the student's performance
in the seminar was evaluated on the basis of "participation." Student follow-
up over a several-year period showed an increasing frequency of selection
of family practice residencies by students taking the clerkship.
A community-based medical education experience was offered through
the Appalachian Health Services Manpower Development Project out of
the University of North Carolina.2i Fifty-five percent of the student's time
was spent with the preceptor, either in the office or hospital; 5-10 percent
of time was spent in a "nonhealth related" community service; 15 percent
in "other community health services," and 10 percent time on a student
pro ject. Evaluation showed an increased awareness among students of com-
munity needs. Fourth-year students preferred the clinical experience and
younger students the community experience. Students felt 6 weeks was
long enough, while clinical preceptors felt the program should be at least
8 weeks in length.
The Upper Peninsula (UP) program of the Michigan State University
(MSU) College of Human Medicine described by Werner et al.22 presents
a complete revision of a medical school curriculum stressing primary care
as the unifying thread of all training. Located in a remote site (the Upper
Peninsula of Michigan) and taught by a special primary care faculty and
community physicians, this 10-students-a-year program uses separate ad-
mission criteria and evaluation standards that assess success in relation to
the goal of encouraging primary care practice in remote sites. The first
graduating class showed equivalent performance on standard evaluation
measures to other MSU students not in the special program, and 8 of 10
UP students selected a primary care specialty, all in a rural location. 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, pre-
ceptorship 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. The goal of federal programs has generally
been exposure of students to underserved communities in order to see
what it would be like to practice there. Medical-school-sponsored programs
have generally focused on exposure to primary care physicians, largely
family physicians, practicing in the community. While increasing numbers
of medical schools require an ambulatory care clerkship for fourth-year
students, many of these required experiences are still in traditional hospital
OPD's and offer predominantly ER and subspecialty clinic experience. The
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174
PART I THEORETICAL ISSUES
opportunity for continuity is often dependent on the practice organization
of the medical center ambulatory care services. The degree to which primary
care is provided there determines the degree to which students get a primary
care experience rather than merely an ambulatory care experience. Few
preceptorships offer systematic instruction in principles of community med-
icine or the team approach, and the preparation of practitioners for their
role as preceptors is variable.
PRIMARY CARE EXPERIENCE~GRADUATE
The surge in graduate medical education programs for primary care is a
relatively recent phenomenon in the United States, though Stoeckle25 re-
counts a period between 1900 and 1940 when residents at Massachusetts
General Hospital spent nearly one-third of their time in the OPD because
there were 2-3 times the number of outpatients tO be seen daily as there
were beds in the hospital. He maintains that the hospital's economy and
work have determined the content and sequence of residency training,
rather than any educational considerations.
The specialty of family medicine was created in 1969, and, with strong
federal financial support, residency programs mushroomed from 15 in 1969
tO 364 in 1979. Most medical schools now have a department or division
of family medicine, and nationwide about 13.6 percent of graduating stu-
dents are now selecting family medicine for residency training.
Family medicine programs have tended to stress the principles of primary
care elucidated in our original definition. This usually includes training in
internal medicine, pediatrics, psychiatry, surgery, and OB/Gyn in a hospital
setting (frequently a community hospital) as well as a continuity of care
experience in a "family practice unit" a model practice developed for the
residency in which faculty and residents, often in a team organization with
other health professionals, serve a defined population. The family practice
unit may be community-based (off-site) or may be hospital-based. In some
institutions, the family medicine unit serves as the outpatient service for
the hospital. The curriculum stresses comprehensive care for the patient in
the context of his family, psychosocial skill building to maximize the ef-
fectiveness of stability of the doctor-patient relationship, and a variable
amount of attention to issues of community medicine.
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 med-
icine 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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Medical Education and Training
175
resources to meet community needs more adequately." Of 39 percent of
the programs responding to the survey, only 38 percent indicated that they
taught techniques for evaluating the health care needs of a community.
Thirty-six percent taught issues and strategies involved in the organization
of health services to meet community needs. 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. These programs and six residency programs funded
by DHEW contracts in 1973 (some of which were the same were the
precursors of the programs in general internal medicine and general pe-
diatrics that increased dramatically (from 63 to 109) during the period of
1976-1980 with the impetus of federal funding under PL 94-484. They
stressed the development of a primary care experience for internists and
pediatricians seeking to become primary practitioners. Most were based in
academic health centers and utilized converted hospital OPD's or group
practices for the resident continuity experience. In Rosinski's study of the
Johnson programs, he found that only two programs provided an oppor-
tunity for residents to take nonclinical electives. One allowed 3 months of
electives with weekly seminars in epidemiology, environmental health, so-
ciology, political science, and quality of care assessment. Another offered
elective opportunity to learn office practice management, sex therapy, de-
cision theory, and behavioral science teaching. The overall evaluation of
the programs was variable, but a consistent dissatisfaction was noted when
the practice site was poorly organized. Residents expressed a desire for
more structured approaches to the learning of primary care.27
After the inital contract period, a major federal grant program was launched
in 1976 in support of general internal medicine and general pediatrics
residency training. To be eligible for federal funds, programs had to meet
. . .
certain crlterla:
1. Twenty-five percent of residents' time had to be spent in a continuity
ambulatory care practice over 3 years (for at least 9 months in each year).
2. Behavioral science teaching had to be integrated into the residency
. .
tralnlng.
3. The practice site had to be organized to assure smooth provision of
. .
primary care services.
4. The team approach was encouraged.
5. The introduction of"nonclinical" subjects related to primary care,
e.g., epidemiology, organization of health services, health economics, etc.,
was encouraged.
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176
PART I: THEORETICAL ISSUES
Though no systematic assessment has been done of the teaching of these
"nonclinical" areas, informal data appear to indicate that most are seminars
on a weekly or monthly basis; some are elective opportunities in community-
based agencies or projects, but there is little systematic teaching of a cur-
riculum in community medicine. While some general pediatric and general
medicine residencies offer the continuity experience in a community-based
practice site, the vast majority feature hospital-based practice models.
An exception to the hospital-based continuity experience and the low
emphasis on community medicine has been the residency program in social
medicine at Montefiore Hospital.28 Started in 1971 as an integral part of
the medical program at the Martin Luther King Health Center in the South
Bronx, the program was designed to train physicians as members of health
teams for inner-city practice in underserved areas. Up to 5 months of time
is made available for social medicine electives during the 3 years of resi-
dency, and a regular Tuesday night curriculum in social medicine is offered.
Over the years, there has been a trend toward increased structure for this
social medicine time.
There is now a core curriculum in social medicine, including epide-
miology, organization and financing of health services, and community as-
sessment. All residents will be expected to take part in the curriculum and
complete a required social medicine project. While efforts are being made
to further integrate social medicine and clinical teaching, the lack of ad-
ministrative control over the practice site creates obstacles to developing
needed practice systems. 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 pro-
gram in family medicine and preventive medicine. Montef~ore offers a
Master's in Public Health degree with a clinical residency program, and
residency programs can be combined with master's programs in community
medicine at Utah, community health at Rochester, and business/public
administration at the Wharton School, University of Pennsylvania. In ad-
dition, postresidency fellowship opportunities are increasing in individu-
alized programs of health administration, health services research, manage-
ment or health policy for example the Johnson Clinical Scholars and recently
the Kaiser Fellowships in Epidemiology (Beth Israel). However, with these
few exceptions, residency training efforts in primary care have focused
largely on the teaching/learning of primary care as defined by Alpert and
Charney.
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Medical Education and Training
COMMUNITY ORIENTED EDUCATIONAL EXPERIENCES
177
While primary care has joined the vocabulary of medical education, com-
munity is not a commonly used word in educational course titles in medical
schools or in residency program rotations. The most recent introduction
of the community to medical education in the United States began to a
great extent during the ferment of the 1960s. 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 ra-
tionalized 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 stu-
dents 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 educa-
tion activities has remained controversial and thus problematic. In 1963-
1964 the Student Health Organization (SHO) was begun in Los Angeles
and Boston. This interdisciplinary group of health profession students shared
concerns about social issues and the role of the health professions in ad-
dressing them. In 1966 the California SHO placed more than 90 students
in rural and urban settings throughout the state with the financial support
of OEO and the University of Southern California. The following summer,
similar student health projects in Chicago, New York, and California placed
more than 250 students of medicine, nursing, dentistry, law, etc., in com-
munity service projects. Madison32 describes three goals for the SHO com-
munity project in the South Bronx, goals that generally characterized these
programs:
. to provide an educational experience in community medicine;
. to stimulate community action for social change; and
. to provide direct services to community residents.
.
Different groups of student participants assigned different priorities to these
goals. Because the projects were organized by students, the goal of com-
munity action became preeminent. Expectations were high for seeing sig-
nificant impact in the community during the project period. When this did
not occur over the few weeks allotted, frustration and disillusionment set
in among activist students. The role of students in direct service remained
unclear, as most were not yet clinically trained. The community medicine
OCR for page 187
Medical Education anal Training
187
I am asking those young doctors who will be the innovators of their generation
to do more than excellent transactional care . . . and begin to explore this new
dimension of anticipatory care of whole populations.47
This is the challenge of education for community oriented primary care,
and I believe it can be met.
REFERENCES
1. Geiger, H.~. (1982) The Meaning of Community Oriented Primary Care in
the American Context. Paper presented at Institute of Medicine Conference
on Community Oriented Primary Care, Washington, D.C.
2. McDermott, W. (1978) Medicine: The Public Good and One's Own. Perspect.
Biol. Med. 21(Winter): 167-87.
3. Fulop, T. (1978) Trends in Education of Health Personnel Worldwide. P. 21
in R.W. McNeur, ea., The Changing Roles and Education of Health Care Personnel
Worldwide in View of the Increase of Basic Health Services. Philadelphia: Society
for Health and Human Values.
4. Delaney, F.M., ed. (1977) Low Cost Rural Health Care and Health Manpower
Training: 3. International Development Research Center, IDRC-093e, Ottawa,
Canada.
5. World Health Organization (1980) The Primary Health Worker: Working Infidel
Guidelines for TraininglGaidelines for Adaptation. Geneva: World Health Or-
. .
ganlzatlon.
Guerrero, Rodrigo (1978) Use of Primary Health Care Facilities in South
America in the Training of Health Professionals. P. 112 in R.W. McNeur, ed.
(see reference 3).
7. Martin Luther King, fir., Health Center (1974) Training Community Health
Workers, 1966-1974. 3674 Third Avenue, Bronx, NY 10456.
8. Geiger, Ho. (1972) A Health Center in Mississippi A Case Study in Social
Medicine. Chapter 13 in Lawrence Corey, Steven E. Saltman, and Michael F.
Epstein, eds., Medicine in a Changing Society St. Louis: C. V. Mosby.
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bridge: Ballinger.
10. U.S. Department of Health and Human Services, Health Resources Admin-
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Publ. No. (HRA) 81-655.
11. Stelling, J.G., and Bucher, R. (1979) Professional Cloning: The Patterning of
Physicians. In E.C. Shapiro and L.M. Lowenstein, eds. In Becoming a Physician.
Cambridge: Ballinger.
12. Steinwachs, D.M., Levine, D.M., Elzinger, D.J., Salkever, D.S., Parker, R.D.,
and Weisen, C.S. (1982) Changing Patterns of Graduate Medical Education.
N. Engl. J. Med. 306(January 7)1:10-14.
13. Wilson, S.R. (1981) An Analytical Study of Physicians' Career Decisions Regarding
Geographic Location: Palo Alto, Calif.: American Institutes for Research in the
Behavioral Sciences.
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188
PART I: THEORETICAL ISSUES
14. Fruen, M.A. (1980) An Overview of the Medical Education System and Its
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Prodest.
15. Heald, K.A., Cooper, J.K., and Coleman, S. (1974) Choice of Location of Practice
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16. Albert, T.~., and Charney, E. (1974) The Education of Physicians for Primary
Care. U.S. DHEW Bureau of Health Service Research, DHEW Publ. No.
(HRA) 74-3113.
17. National Academy of Sciences, Institute of Medicine (1978) A Manpower Policy
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18. U.S. Department of Health, Education, and Welfare, Health Resources Admin-
istration (1978) Influence of Preceptorship and Other Factors on the Education
and Career Choices of Physicians; Executive Summary, p. 2. DHEW Publ. No.
(HRA) 78-74.
19. Morrison, A.P. (1978) Medical Student Psychiatric Education in Neighborhood
Health Sertings..~. Med. Edge. 53:994-96.
20. Buttery, C.M.G., and Moser, D.L. (1980) A Combined Family and Community
Medicine Clerkship. Fam. Pract. 11(2):2 37-44.
21. Key,.J.C., Stritter, F.T., and Allison, E.J. (1973) Community-Based Medical
Education. North Carolina Appalachian Health Services Program. Ned. Med.
J. 34:360-64
22. Werner, P.T., Richards, R.W., and Fogle, B.~. (1978) Ambulatory Family Prac-
tice Experience as the Primary and Integrating Clinical Concept in a Four Year
Undergraduate Curriculum..~. Fam. Pract. 7(2):325-32.
23. Segall, A., Margalit, C., Benor, D., and Susskind, O. (1977/1978) The Beer-
Sheva Experiment in Early Clinical Instruction. Reprinted from K~pat-Holim
Yearbook 6.
24. Kaufman, A., Obenshain, S.S., et al. (1980) The New Mexico Plan: Primary
Care Curriculum. Public Health Rep. 95(1):38-40.
25. Sroeckle, T.D., Leaf, A., Grossman, T.H., and Goroll, A.H. (1979) A Case
History of Training Outside the Hospital and Its Future. Am. J. Med. 66: 1008-
14.
26. Donsky, J., and Massad, R. (1979) Community Medicine in the Training of
Family Physicians. Fam. Pract. 8(5):965-71.
27. Rosinski, E.F., and Dagenais, F. (1978) Resident Traizzingfor Primary Care. San
Francisco, Calif.: Office of Medical Education, School of Medicine, University
of California.
28. Boufford, J.I. (1977) Primary Care Residency Training: The First Five Years.
Ann. Intern. Med. 87(3):359-68.
Werblun, M.N., Dankers, H., Betton, and H., Tapp, J. (1979) A Structured
Experiential Clerkship in Community Medicine,]. Fam. Pract. 8(4):771-74.
30. Maloney, W.F. (1967) Tufts Comprehensive Community Health Action Pro-
gram. J. Am. Med. Assoc. 202(5):109-12.
Deuschle, K.W., Fulmer, H.S., McNamara, M.T., and Tapp, J. (1966) The
Kentucky Experiment in Community Medicine. Milbank Mem. Fund Qz`. 44:
9-22.
32. Madison, D. (1968) The Student Health Project: A New Approach to Edu-
cation in Community Medicine. Milbank Mem. Fund Qa. 46:389-407.
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189
33. McGavran, E.G. (1978) Scientific Diagnosis and Treatment of the Community
as a Patient. J. Am. Med. Assoc. 162(8):20.
34. Schwarz, K. (1977) A New Integrated Course in Preventive and Community
Medicine. Med. Edac. 11 :267-70.
35. Geiger, He. (1980) Sophie Davis School of Biomedical Education at City
College of New York Prepares Primary Care Physicians for Practice in Un-
derserved Inner City Areas. Public Health Rep. 95(1):32-37.
36. Bennett, Fly. (1981) Community Diagnosis: Its Uses in the Training of Com-
munity Health Workers and in Primary Health Care in East Africa. Isr. }. Med.
Sci. 1 7(2-3): 129-37.
37. Deuschle, K.W., and Bosch, SJ. (1981) The Community Medicine-Primary
Care Connection. Isr.~. Med. Sci. 17(2-31:86-91.
38. Morrell, D.C., and Holland, W.W. (1981) Epidemiology and Primary Health
Care. Isr.~. Med. Sci. 17(2-3):92-99.
39. Kark, S.O., Mainemer, N., Abramson, T.H., Levav, I., and Kutzman, C. (1973)
Community Medicine and Primary Health Care: A Field Workshop on the
Use of Epidemiology in Practice. Intern. Epidemiol. 2(4~:419-26.
40. Kindig, D.A. (1975) Interdisciplinary Education for Primary Health Care Team
Delivery.1. Med. Edac. 50(12):97-110.
41. Institute for Health Team Development (1978) Final Report. New York: Mon-
tef~ore Hospital and Medical Center.
42. U.S. Department of Health, Education, and Welfare, Health Resources Admin-
istration, Bureau of Health Manpower (1976) Workshop on Interdisciplinary
Team Education, Snowbird, Utah.
43. Rubin, I.M., Plovnick, M.S., and Fry, R.E. (1977) Improving the Coordination
of Care: A Program for Health Team Development. Cambridge: Ballinger.
44. Wise, H.W., Beckhard, R., Rubin, I., and Kyte, A.L. (1974) Making Health
Teams Work. Cambridge: Ballinger.
45. Tichy, M.K., ed. (1974) Health Care Teams: An Annotated Bibliography. New
York: Praeger.
46. Madison, D., and Shenkin, B. (1978) Leadership for Community Responsive Prac-
ticc Preparing Physicians to Serve the Underserved. Rural Practice Pro Act, School
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Phys. Lond. 48(4):299-314.
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190
Discussants
PART I: THEORETICAL ISSUES
Robert Tranq~ada
I have approached this assignment from the pragmatic point of view of a
medical school dean who presides over the processes of allocation of re-
sources in the academy, those fiscal and space and personnel decisions whose
sum makes up the character of the school itself. I must view the subject
of education for COPC from this vantage point, because that is where I
am.
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 Depart-
ment from three separate departments to one significant whole, which was
probably one of the more unnoticed but greatest ventures in recent times.
Moving a very large county health department into a mode that embodied
much of what is involved in COPC is no small undertaking.
The department of community medicine that I founded is now almost
entirely devoid of anything that might be called community medicine and
is concentrating entirely on very sophisticated not unnecessary, but very
sophisticated epidemiology. The Los Angeles County Department of Health
Services has been gradually torn asunder and dismantled towards its more
primitive mode of specialized areas of hospitals, mental health, and public
health. The Watts Health Center continues to struggle successfully in spite
of diminishing federal support.
As a dean, I have to ask myself why this retrogression from so much
promise 15 or more years ago and how can more lasting results be achieved
from the enterprise in education for COPC. In short, what can we do to
ensure that education for COPC can have a significant role in today's medical
school training? What can we do?
No matter how dedicated we may be to the cause, we are constrained
to operate within the resources made available. Because of the nature of
the sources of those resources, our degrees of freedom in shaping their use
are practically limited. We must respond to the fiscal and political realities
that keep our institutions housed and our programs fed. A moribund in-
stitution isn't going to produce anything, much less COPC oriented stu-
dents. What are the realities then from the dean's perspective?
Dr. Boufford refers to the important effect of student attitudes on in-
stitutional climate. As a participant at USC in the days of the Bronstons
and McGarveys and the Student Health Organization, I can attest to the
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Medical Education and Training
191
veracity of that observation. In my own school, over the past 6 years, in a
school dedicated to the production of primary care physicians, 75 percent
of our graduates have entered the primary care specialties of family practice,
internal medicine, or pediatrics, against a national average of about 52
percent. This year, the indicators are that no more than 55 percent will do
so. While this may well prove to be simply an aberrant class, we cannot
help but look at the burden of debt at high-interest rates that they are
taking with them and speculate that low-earning primary care roles are
simply not attractive, in spite of our best efforts. We must face the realities
of the economic burdens now shouldered by the majority of our graduates
and consider how these realities will influence career choices. All indications
are that they will get worse and not better in the next few years.
We in the medical schools continue to struggle to find experienced and
capable faculty to staff our primary care programs. The immense growth
in these programs, the 20-fold growth that Dr. Boufford mentioned as
happening over the past 12 years, has left an enormous gap in the availability
of seasoned faculty expert in primary care fields to teach and serve as the
very significant role models that we need. Too many of those that are
available or that we are able to bring on board are either from other
backgrounds or are young products of what must be described as immature
and tentative primary care training programs, which have had great difficulty
in defining themselves in terms that are clear and understandable. A recent
report in the Arznals of l~terr~al Medicine on primary care internal medicine
programs in the United Statesi reveals that only 11 percent of the faculty
of such programs are specifically trained in primary care internal medicine.
Thirty-five percent come from subspecialties and 30 percent come from
chief residencies in traditional internal medicine programs. We have a man-
power 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. In the
more-or-less global definitions that have been used, the talk about cultural
anthropology, sociology, biostatistics, and epidemiology points in a general
direction only. There is a need for definition of the field in product-oriented,
cognitive, and measureable terms in just the same way that we can define
vascular surgery or gastroenterology. Only in this way can we expect the
other specialized faculty to come to some understanding of what it is really
all about and to increase their respect for the practitioners of these vital
primary care areas. More explicit and understandable descriptions of the
expected roles of COPC-trained physicians, better standardized curricu-
lu~you will forgive me for that, but I will make the point again and
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PART I: THEORETICAL ISSUES
much clearer translations of the utility of the nonclinical portions of the
curriculum are required for those purposes.
Funding is increasingly a problem. Our primary care departments and
training programs are all deep in the red. They are supported by reluctant
subsidies from the earnings of the rich departments and surreptitious al-
locations from general funds through the dean's office, which are being
questioned more and more. As we move closer to the limits of funding of
medical education and justification of these methods, the willingness of
other departments to share scarce resources will become increasingly more
difficult. The dean's task of supporting these efforts will be more and more
subjected to pragmatic considerations, most of which are unfriendly to the
charter of COPC.
Funds for subsidizing the settings in which COPC has grown are dis-
appearing. The litany is familiar to you all: The OEO is gone; Community
Health Center funding is under increasing attack from the current Admin-
istration; block grants threaten many backbone programs to which we are
tied; and medical school capitation is dead. The private foundations cannot
be expected tO pick up all the slack. Faculty resistance remains. We have
not yet made our case with the rest of the faculty. We are seen as do-
gooders who are concerned with special systems applicable only to captive
populations or to the disadvantaged, and what does that have to do with
real life? The definition of what we are doing remains vague and unclear.
Besides, the money well has dried up and where is the incentive? Traditional
university and medical faculty appointment and promotion systems do not
work well for any but the most outstanding faculty in COPC. Such systems
tend to force well-motivated faculty to ignore hands-on issues and to return
to the bench or the calculator.
Objective incentives to students who aim for COPC practice do not exist.
Wellness care is not paid for, nor home visits, nor nutrition counselors,
nor, I am sorry to say, teaching nurse practitioners, nor epidemiologic
studies of communities, nor most of the intervention methods that have
been mentioned. Unless a program of universal entitlement arrives, this
will continue to be the case. This is a very tough reality with respect to
incentives for all of us who would move in this direction.
It is a discouraging picture, at least to this dean, and the question, of
course, is where do the solutions lie? I am not sure I know where they all
lie. What positive actions are most likely to move medical school education
for COPC on to a firm foundation? Time obviously doesn't allow a detailed
discussion, and I will just briefly outline a few recommendations.
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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Medical Education ant! Training
193
of public health has been infectious disease. Politically, this has been trans-
lated into the task of keeping the dirty diseases of the poor away from the
thresholds of the rich. That has made traditional public health supportable
as a governmental activity at public expense. 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.
We cannot rely on that alone. We need a much sharper operating defi-
nition of the cognitive requirements of COPC. Even if we are wrong in
our first Cut at this, sharper definitions will diminish the not totally unearned
view in which we are now held as muddle-headed idealists. If we are wrong
with our first definitions, we can change them as we learn. Those cognitive
definitions must be translated into a clearly defined and more standardized
curriculum. We are at a point where I believe that too much room for
innovative programs leaves us without any standards against which we can
ask to be judged.
We must concentrate on the development of a significant cadre of out-
standing teachers of COPC. Two or three or four centers ought to be
established with clear mandates, objectives, and well-defined curricula to
help us with the preparation of outstanding teachers and to produce the
seminal supply for the rest of the country. That is how every strong program
in clinical medicine had its beginning, and I believe it must be the foundation
if there is to be a strong academic program in COPC.
We must concentrate on the development of clear evidence of the ef-
fectiveness and efficiency, the health and economic advantages of COPC.
If we can not do this, we can kiss the idea goodbye. Expensive idealism in
health care will not be tolerated on any significant scale in the next several
years.
We should, effectively, hole up for the winter while these other tasks
are being achieved. We should concentrate on preserving only the best
programs, which can tide themselves over with modest foundation support.
A half-dozen innovative and excellent academic centers nationally are prob-
ably all that can be well-supported in the short run. These should be re-
sponsible for programs of visitation, seminars, preparation for academic
roles, and development of meaningful accreditation requirements for less
favored programs.
We must develop models of COPC clearly applicable to circumstances
other than the special or marginal populations with which we have done
most of our work; middle-class HMOs, group practices, or segments of
university practices come to mind as logical places to start. It is a significant
challenge. Otherwise, we must consign ourselves purely to a role of applying
these principles to captive or disadvantaged populations only. Nevertheless,
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PART I: THEORETICAL ISSUES
we must continue to utilize the special settings where nascent or mature
programs have evolved.
Finally, we must divorce ourselves from the image of the fuzzy-minded
do-gooder and create a well-defined, hard-headed discipline that can eval-
uate its achievements in other than emotional terms and that is unified by
a clear understanding of its boundaries and its central themes. There is a
lot of work to do. Times are hard. Stakes are certainly high. Certainly others
will differ from what I have said here, but from the perspective of this
dean's chair, something akin to the preceding is required if COPC is to
come of age in medical education.
REFERENCES
1. Friedman, R.H., Rosen, J.T., Rosencans, K.L., Eisenberg, J.M., and Gertman,
P.M. (1982) General Internal Medicine Unites in Academic Medical Centers
Their Emergence and Functions. Ann. Inter. Med. 96:233-38.
Richard Kozoll
I presume that my comments follow Dr. Boufford's and Dr. Tranquada's,
because I am a physician in the current practice of community oriented,
responsive, centered, or guided medicine. What I do confess to is the
leadership of a very unusual community practice. I believe that I am in the
practice of community oriented primary care, but I am certain that many
of my patients are unaware of it. My board of directors probably suspects
it because my revenues rarely exceed my expenses. It is probably my wife
who really knows it, because our incidence of uninterrupted suppers rarely
exceeds 300 or so per thousand. In fact, you might talk in terms of com-
munity oriented life.
Dr. Boufford has identified a number of critical components and cate-
gories of preparatory experience for community oriented primary care.
However, I do not feel that these really reflect the inventory of knowledge
or skills that I need for the day-to-day operation of a rural health system,
. . .
my community orlentec . practice.
I have attempted a list. Forgive me for its length, but I assure you that
these are all areas of knowledge or skills that I either have developed,
learned indirectly, or am in need of. They include clinical problem solving;
behavioral intervention, including individual patient counseling and edu-
cation; personnel management, including salary and wage administration;
job description development; motivational and team leadership skills; fiscal
management, including budget formulation and monitoring; accounts re-
ceivable and payable management and nonprofit accounting procedures;
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Medical Education and Training
195
grant preparation and contract negotiation; data systems use; public rela-
tions, including the development of informational materials; other market-
ing skills and media use; public communications skills, which must be adapted
for three cultural and language groups; nonprofit corporate board organi-
zation and function; knowledge of federal, state, and local agencies and
health programs; knowledge of third-party covered services and reimburse-
ment procedures; emergency medical system development and operation;
school health service development and operation; clinical protocol devel-
opment and quality of care evaluation techniques; community hospital or-
ganization and medical staff responsibilities; Joint Commission on Accre-
ditation of Hospitals and/or federal program certification requirements for
clinics and hospitals; facility financing and construction; other physical plant
requirements, including fire safety codes; development of patient education
materials; knowledge of other health professions, including licensure or
certification requirements, regulations, and professional capabilities (part of
the knowledge needed to organize an appropriate health care team); and
principles of population medicine, including use of census and vital statistics
data, rate determination, and research design.
Perhaps the most important skill of all is personal time management, one
I have not yet mastered. These skills are not conveniently offered by any
physician-training program in the United States of which I am aware. I
agree with Dr. Boufford that the present schism in the United States be-
tween public health and medical practice may impede the development of
training programs integrating these two different perspectives.
The impediments, I think, are overcome by an appropriately motivated
health professional in training, as well as a flexible training program. I know
of many others as well. I feel that I was able to overcome them, and I know
of many others who did as well. So much then for the knowledge and skill
requirements for COPC.
Dr. Boufford has alluded to community role models as an important
factor in education for community oriented primary care, and I agree whole-
heartedly and have served from time to time in this capacity for student or
resident preceptees from the University of New Mexico. I believe, however,
that several predisposing conditions must be met for the role model ap-
proach to work. First, the students or residents must be activated. They
must fully elect the experience. They must be able to participate actively
in their own education. They must feel comfortable in interacting with the
teacher or preceptor tO whom they are assigned. I feel that development
of such activated students is the responsibility of training institutions.
Secondly, the student or resident must make an informal contract with
the preceptor. The time and economic demands of the preceptor preclude
the continuous sort of attention that full-time faculty may be able to provide.
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PART I: THEORETICAL ISSUES
The preceptee may need to help out in certain practice situations in order
to free up the preceptor for later one-to-one sessions. This sort of trade-
off should be negotiated in advance and should not suddenly and begrudg-
ingly occur in the busy practice situation. The structure of the preceptorship
should be negotiated early on to the satisfaction of both parties. Awkward
inactivity and inappropriate responsibility for the preceptee may be avoided
through this negotiation process.
Thirdly, the preceptor must be prepared to share his or her entire life
with the preceptee. In this way the preceptor's personality, as well as his
or her professional function, influences practice choices of the preceptee.
And, finally, the chosen practice must be stable, successful, and of high
integrity. I think both Dr. Boufford and Dr. Tranquada referred to this
point. The potential for "turn-off'' rather than "turn-on" should be mini-
mized if medical schools are careful in their choice of community oriented
practices. The potential for future replication of the practice by the pre-
ceptee, I would think, would be enhanced by an early "turn-on" experience,
rather than one of a different kind.
I would now like to reinforce the importance of the timing of precep-
torships and other community experiences. I think they should begin early.
Dr. Boufford has referred to the concept of ideology or perhaps the pre-
vailing attitude of the microsociety of which the medical student is a part.
I think this ideology is most flexible in the initial few months of medical
school.
Students must leave the classroom, and they must leave the academic
center, even for just a month. We have seen examples all around us of
community oriented health professionals who participated vigorously during
the 1960s in student projects. The approach works. I know it does. I was
one of those students. Students identified as being predisposed to com-
munity oriented primary care need to be continually reinforced. It is going
to be an uphill battle for them. Electives, fellowships, special projects, and
further role model assignment must follow. They should be, and they should
feel favored in their schools.
The Checkerboard Area Health Systems participates in a unique program
at the University of New Mexico, called the Primary Care Curriculum. We
were fortunate to have assigned to our health system two students from
their initial class and one student of their second class for a 6-month, second-
year, rural health rotation. We are gratified that all three of them are coming
back during their fourth year and we intend to reinforce whatever prelim-
inary decisions they may have made. I think more of this should take place.
I would also like to make an argument for including more structure in
the community preceptorship. I agree with Dr. Tranquada in this regard.
I would like to mention that the structure would help not only the precept - ,
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Medical Education and Training 197
but also the community preceptor as well. Everybody would be more com-
fortable, and the students may feel that community medicine is far less
alienated from other areas of medical expertise.
Like Dr. Boufford, I am not willing to write off the influence of medical
education on physician career choices. The existing community oriented
. .. . . . . . . . .
primary care practitioners in conjunction Alto ~ innovative training programs
can, I believe, shape or at least significantly influence the future of American
. .
mec .lclne.
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.
Representative terms from entire chapter:
community medicine
