|
Items in cart [1] |
Questions? Call 888-624-8373 |
| Copyright © 2009. National Academy of Sciences. All rights reserved. Terms of Use and Privacy Statement |
Below are the first 10 and last 10 pages of uncorrected machine-read text (when available) of this chapter, followed by the top 30 algorithmically extracted key phrases from the chapter as a whole.
Intended to provide our own search engines and external engines with highly rich, chapter-representative searchable text on the opening pages of each chapter.
Because it is UNCORRECTED material, please consider the following text as a useful but insufficient proxy for the authoritative book pages.
Do not use for reproduction, copying, pasting, or reading; exclusively for search engines.
OCR for page 264
Departments of Family
Practice as Vehicles for
Promoting COPC
Thomas M. Melee and lack H. Medalie
Case Western Reserve University School of Medicine in Cleveland, Ohio,
under Dean Joseph Wearn, made medical history in the 1950s and 1960s
by radically revamping its entire curriculum. Among the many innovations
introduced were:
. a strong student orientation with their participation in planning, pre-
cepting, and evaluation, as well as self-educational facilities and initiative;
· an integrated carric~m;
· interdisciplinary subject committees;
multidisciplinary labs;
. beginning medical school with a live human contact (pregnant woman)
rather than a cadaver; and
. 7 months of electives in the final year and a required ambulatory clerkship.
The view has been expressed that it was "the most significant develop-
ment in medical education since the Flexner Report." Many medical schools
since the 1960s have adapted aspects of the curriculum, while McMaster
University in Canada and the University of Limburg at Maastricht in the
Netherlands have gone even further in their integration. The spirit of
readiness to try new ideas at Case Western Reserve University continued,
and in 1974, under Dean Frederick C. Robbins, the faculty voted to create
a department and discipline of family medicine that would have status equal
to other departments.
Today, the Department of Family Medicine (chairman, J. H. Medalie)
264
OCR for page 265
Departments of Family Practice
265
consists of four clinical departments at university hospitals, the Cuyahoga
County Hospital system, Fairview General Hospital, and Mount Sinai Hos-
pital. Three of these hospitals have accredited residency training programs
with 44 physicians in training. In addition, we have four Robert Wood
Johnson fellows in training for an INS. (family medicine) program. The
department also has three divisions based at the School of Medicine. These
are: research, education, and family/behavioral science. The department is
heavily involved in education of medical students, residents, postgraduates,
faculty, and continuing medical education.
The following illustrates the community orientation of the department.
It provides a more detailed look at the activities of one of the clinical units,
the Department of Family Practice at the Cuyahoga County Hospital system
(director, T. M. Mettee).
The department and residency training program are currently in their
sixth year of operation at Cleveland Metropolitan General/Highland View
Hospital the acute care/rehabilitative care hospital in the Cuyahoga County
hospital system. The educational program derives much of its strength from
itS affiliation with Case Western Reserve University's Department of Family
Medicine described above. Special strengths in epidemiology, research,
education, family sociology, family psychiatry, and community medicine
have made major contributions to our community orientation and faculty
development.
A Health Resources Administration-sponsored training grant provided
us with resources to establish a vital link with the Department of Medical
Anthropology at Case Western Reserve University. This linkage put US in
contact with J. Kevin Eckert, Ph.D., a medical anthropologist with a special
interest in the urban elderly. Through his leadership a number of graduate
students have carried out research in our target area, and we have hired
one student, full-time, to coordinate and manage the activities of our com-
munity outreach project (to be described later). These affiliations with
university-based departments are without a doubt the key to our community
oriented approach to service and education. The current challenge is to
distill and synthesize information, concepts, and methods from the disci-
plines represented by these affiliations, especially epidemiology and the
behavioral sciences, in order to articulate practical approaches to community
oriented primary care, which can be applied by the primary care practitioner,
who usually functions without such university support.
At the undergraduate level, our department and Family Practice Center
serve as a site for elective Medical Apprenticeship Program (MAP) students
(first and second year), who work in a patient care tutorial one-half day per
week for 6 weeks with a resident, fellow, or faculty physician to gain
exposure to a community responsive practice. The center also serves as a
OCR for page 266
266
PART II: PRACTICAL APPLICATIO NS
site for the required ambulatory/primary care clerkship—a 2-month rotation
for fourth-year students. Unique features of that clerkship are:
· an in-depth family case study that includes a home and neighborhood
assessment; and
. a community project that is student-initiated and family physician/
anthropologist faculty-supervised, requiring data collection and resource
... .
utilization in our target area community.
One student community project surveyed target area industries, mapping
the location of those work places and identifying all those considered "high
health hazard" regardless of work force size. This proved to be an enlight-
ening exercise, as it identified most hazardous work places as small (less
than 50 employees) businesses some of which were located in residential
neighborhoods. It also identified a lead smelter next to a playground, a low-
income housing area, and the confluence of two interstate highways. Our
awareness that these geographically intermingled sites might have produced
an endemic lead poisoning situation caused us to plot geographically all the
lead levels performed by the health department screening program. Our
suspicion was confirmed, and subsequent education and interaction with
the health department has occurred. Whether there is a cause and effect
relationship between these environmental lead sources (highways and smelter)
and toxic lead levels in these children remains to be seen. The fact remains
that a student-initiated community project was responsible for making the
. .
assoclatlon.
Another undergraduate activity, sponsored and supported by the Medical
School Department of Family Medicine, is the summer fellowship program.
Over the past three summers, one student has spent July and August
assisting in a data collection process focused on community diagnosis. Their
work has led to a multivariate factor analysis of our target area, a better
understanding of the needs of the Hispanic community, and a method for
screening patients for occupational illness. Our practice center services are
now trying to adapt and become more community-responsive based upon
this work.
At the graduate level our Family Practice Residency Training Program
focuses its recruitment on students with urban interests and community-
responsive attitudes who are eager for community involvement and social
change. Our practice center has identified a geographically bounded target
area composed of 38 census tracts with a shortage of primary care health
manpower. This provides us with a denominator population characterized
as a multiethnic urban community of lower socioeconomic status. Our
orientation program for new residents emphasizes community diagnosis,
OCR for page 267
Departments of Family Practice
267
community resources, belief systems, explanatory models, home visits, in-
dustrial survey and work place visitation, and target area exploration.
A special feature of the department is a multidisciplinary study group of
family physicians, residents, students, anthropologists, social workers, ep-
idemiologists, sociologists, and family therapists all engaged, to various
degrees, in a community outreach project. One of the major goals of this
activity has been the study of concepts of community diagnosis as an ex-
tension of individual and family diagnosis, i.e., viewing the community as
a patient. We have reviewed community history and sought opinions from
key informants, interest groups, political factions, local media, and individual
citizens (including our own patients) in order to collect subjective data. Our
community physical exam has been done on foot, in mini-buses, and in cars
(often with a camera) to survey the geophysical environment and established
. . . .
community resources anc institutions.
Census data, health department data, police records, and planning agency
data were collected. With the use of census tract, geophysical, and lot line
maps we have plotted much of this data in order to "see" our patient the
ORGANIZATION OF CARE
"POPULAR, FOLK, SELF HELP"
EPIDEMIOLOGY'\ ~ ~ SCIENCE ~
1~ ~
~ .
ORGANIZATION OF CARE
"PROFESSIONAL"
~ Hi,
I: :-:-:-:-:-:-:-:-:-:-:-: _~:-
................................................
................................................
............... -.-.- - -.-.-.-.-.-.-.-.- -.-
................................................
:~:: :~:~:~:~:~:~:~:~:~:~:~:. al lo en A I :-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:
- - - ~ ~ ~ ~ ~ · ~ A _
.............. .'
% ~ _
it, ..............
~ .-.-.-.-.-.-.-.-.-.-.-.-.-. . . . . . . . . . . . . . . . .-.-.-.-.-.-.-.-.-.-.-.-.-.~
~ ...........................................
~ '
I. . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . . .#
` '
`-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-' BE L I E F SYSTEMS
`-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.
_ _
`-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-'
_ ,—
`-.-.-.-.-.-.-.-.-.-.-.-.-.- -.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.
- ; ---------.-.-.-.-.-.-.-:-.-.-.-.-.-.-.-.-.-.-.-.-.-'
~---------------------------------------------~
_: . ~
~-.-.-.-.-.-.-.-.-.-.-.-.-.-.-----~
aim _
FIGURE 1 Community oriented primary care.
EXPLANATORY MODELS
OCR for page 268
268 ~ PART Il: PRACTICAL APPLICATIONS
community- more clearly. Factor analysis has been a particularly helpful
technique to reduce large quantities of information to a workable few
without losing the power of our observations. Through this diagnostic proc-
ess, we are developing a problem list and a small number of interventions
or plans that we feel are "community-responsive." Another goal of this
process is the development of a "community diagnostic tool kit" to be used
by our residents in training and in their own communities after graduation.
Hopefully, it can be adapted for use by any physician or health care worker
committed tO community oriented primary care. In conclusion, our group
has developed a Venn diagram that captures for us the concept of COPC
(see Figurel).
Representative terms from entire chapter:
western reserve
