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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

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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

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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

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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 otherfaculty "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

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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. 9. Funkenstein, D. (1978) Medical Stz~der~ts, Medical Schools and Society Daring Five Eras: Factors Affecting the Career Choices of Physicians 1958-1976, p. 111. Cam- bridge: Ballinger. 10. U.S. Department of Health and Human Services, Health Resources Admin- istration, Graduate Medical Education National Advisory Committee, Educa- tional Environment Technical Panel (1980) Report of the Panel, p. 19. DHHS 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 Financing. Chapter 2 in.J. Hadley, ea., Medical Education Financing. New York: Prodest. 15. Heald, K.A., Cooper, J.K., and Coleman, S. (1974) Choice of Location of Practice of Medical School Graduates: Analysis of Two Surveys. R-1477-HEW. Santa Mon- ica, Calif.: Rand. 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 for Primary Health Care, p. 5. Washington, D.C.: Institute of Medicine. 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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Medical Edacatio~z and Training 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 of Medicine, University of North Carolina at Chapel Hill. 47. Hart, J.T. (1974) The Marriage of Primary Care and Epidemiology.J. R. Coll. 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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192 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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194 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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196 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.