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Can Area Health Eclucation Centers Promote COPC? The Colorado Experience Karen F. Hansen This paper will provide a brief introduction to Area Health Education Centers (AHECs), in general, to the Colorado program, in particular, and tO the question of whether AHECs can promote COPC. The concept of AHECs was first described by the Carnegie Commission on Higher Edu- cation in its special report Higher Education adze the Natior~'s Health: Policies for Medical and Dental Ed~catiorz, published in October 1970. The com- mission examined the behavior of universities and the federal government prior to 1970 in attempting to correct the significant shortage of health professionals existing at that time and found that the rush to develop new academic health science centers was inappropriate given the extraordinary cost of these institutions. In addressing the health manpower situation at that time, the commission suggested that new health science centers may be appropriate in specific parts of the country; in other parts, however, institutions training health professionals should focus on the more adequate distribution of their resources within their states, without costly new con- struction and duplication. To this end, the commission recommended that academic health science centers develop AHECs in those regions of their states that were without the resources and services of academic health sciences centers. Specifically, the commission recommended the establish- ment of 126 AHECs by 1980 in nearly every state in the country. In 1971, the Comprehensive Health Manpower Training Act was en- acted, which included authorizing language for AHECs under the health manpower initiative awards section. Thus, in 1972, the federal government provided funds to 11 universities to develop the initial experience with 258

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Can Area Health Education Centers Promote COPC? 259 AHECs. Probably the national prototype has been developed at the Uni- versity of North Carolina at Chapel Hill. Following 1972, no new AHEC programs were funded until 1977. Since then, 12 new awards have been made, the latest in 1979. Over this period, the federal government has contributed approximately $160 million dollars to this effort, with state contributions now totalling more than $300 million. There are currently 21 projects in 20 states. A series of evaluation efforts focused on the AHEC programs have been conducted over a period of several years. These studies have included the 1978 report of the U.S. Government Accounting Office; the 1978 report of the U.S. House of Representatives, Appropriations Subcommittee on Health; the 1976 and 1979 reports of the Carnegie Council on Policy Studies in Higher Education; a 1980 report to the Congress by the Secretary of the Department of Health, Education, and Welfare; and the 1980 report of the Graduate Medical Education National Advisory Committee (GMENAC). These reports document a significant impact on the distri- bution of physicians in health manpower in the areas served by AHECs. This is particularly true of the 11 projects originally funded in 1972. The newer projects are too young at this writing to be able to demonstrate an impact on manpower distribution. Individual examples of impact include that demonstrated in the original California project located in Fresno in the central San Joaquin Valley. Positive changes in the AHEC included substantial increases in numbers of physicians compared to declines in physician numbers in the non-AHEC regions. The AHEC showed a net gain of 152 physicians, an increase of more than 20 percent. The University of Illinois has demonstrated a 70 percent retention of family practice residents as a result of its AHEC activity. In addition, 40 percent of clinical training of all University of Illinois medical students is now located in community hospitals. In North Carolina, medical student education is occurring on a regular basis in more than half of the state's 100 counties. In addition, the proportion of North Carolina medical school graduates choosing tO practice in the state has increased dramatically since the beginning of the AHEC program. In 1960, only 30 percent of the state's medical school graduates eventually located in North Carolina; that number has now risen to more than 40 percent of the graduates since 1972. In 1980, two-thirds of the AHEC- trained primary care residents remained in the state to practice. Between 1973 and 1978, the improvement in North Carolina's physician-to-popu- lation ratio was 20 percent compared to 15 percent for the rest of the United States. North Carolina's rural counties have improved their phy- sician-to-population ratios significantly more than other rural U.S. counties. During the first 5 years of the AHEC program in North Dakota, the ratio of physicians per 100,000 population improved from 85.1 to 108.

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260 PART II: PRACTICAL APPLICATIONS The expectation is that with the continuing AHEC residency support, the ratio will continue to improve. South Carolina has demonstrated a doubling of minority physicians practicing in the state, from 39 in 1979 to 84 in 1980. During the AHEC project at Tufts University, 11 percent of un- dergraduate clinical education occurred in AHEC sites in Maine, including third- and fourth-year clerkships at two medical centers and fourth-year preceptorships at six rural sites. The follow-up on students participating in these programs indicates a significantly higher number locating practices in nonrural locations, especially in Maine. Four family practice residencies were developed or expanded in Maine where there were none prior to the AHEC. Seventy-eight percent of the graduates of the residency programs are locating their practices in the state, and 76 percent of those practices are in communities of 10,000 population from 14 to 102 in three hospitals served by the AHEC. In addition, there has been a decrease in the number of residents who are foreign medical graduates in the state. Among the newer programs, Connecticut has provided a significant focus on urban and community health needs. A required primary care clerkship involving 70 senior medical students each year is served in urban health experiences in underserved inner cities. There is a significant focus in the expansion of the family medicine residency program on urban and com- munity health issues and needs. Other newer projects with significant urban focuses include New Jersey, California, Massachusetts, eastern Virginia, Ohio, and Maryland. In Colorado, our evaluation efforts also focus on changing manpower distribution patterns. The first residency graduates having had AHEC stu- dent rotations will complete their residencies this spring. The number is very small. However, one proxy measure of impact that we are using is a significant upturn in the number of Colorado graduates staying in the state for residency training. Since 1978, which was the first year of AHEC student rotations, the percentage of graduates remaining for residency training rose from 26 percent to more than 40 percent in 1981. A more immediate measure can be seen in the employment decisions of nursing graduates. The baccalaureate graduates of the University of Northern Colorado and the University of Colorado are choosing AHEC employment sites much more frequently than they did previously. In 1979, for example, 14 percent of graduates went to work in rural areas, and, in 1981, 26 percent chose rural employment. We also have a significant amount of data on graduating dentists indicating that a student with a rural background given rural ed- ucational rotation will choose a rural practice site almost 100 percent of the time. In Colorado, the AHEC program began as a result of the arrival of the new chancellor of the Health Sciences Center, Dr. John W. Cowee, in

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Can Area Health Ecincation Centers Promote COPC? 261 1976. In traveling throughout the state, he heard repeated complaints that the Health Sciences Center was not appropriately responsive to the needs of the state's practitioners and the health care of rural people. Building on some existing programs, the faculties of the schools of the Health Sciences Center in 1976 and 1977 developed position papers and other activities that formed the basis for an AHEC Proposal to the Department of Health and Human Services that was funded in 1977. The AHEC in this state, called the SEARCH program, is based on community boards of directors, which are locally incorporated and representative of the geographic region they serve. There are four area health education centers serving 53 of the state's 63 counties. As of 1982, all rural areas of the state are covered. AHEC activities do not occur in the metropolitan Denver area or in Col- orado Springs. The activities of the program include an increase in the number of student rotations from UCHSC and other participating schools in medicine, dentistry, nursing, pharmacy, and allied health from 240 in 1978-1979 to more than 500 in 1981-1982. In addition, all of the state's baccalaureate-level nursing education programs are involved in AHEC ac- . . . tlvltles in their particular regions. The educational benefits that accrue to students from AHEC rotations include a more realistic view of primary care delivery than a tertiary care university system is able to provide; more personal attention from the preceptor and/or attending physician than the student has in a crowded university setting; and a more complete understanding of community health systems, including social services, than are evident at the university level. The student also sees more cost-effective health care at the local level. The community benefits as well from AHEC rotations. First, recruiting oppor- tunities are enhanced for communities that are interested in attracting more health providers. This is a particular problem in rural Colorado, especially for nursing, although physician shortages and dental shortages remain as well in certain pockets of the state. A second community benefit is that the professional providers who already live in the area experience reduced professional isolation as a result of contact with students, faculty members from the university, and local continuing education offerings. Thirdly, in- creased professional stimulation and examination of health care attitudes and delivery occur as a result of student participation in community prac- t~ces. The principles of COPC are apparent in Colorado through the SEARCH/ AHEC program in particular. The School of Medicine offers a first-year course, Introduction of Clinical Medicine, which is coordinated by the Department of Preventive Medicine. This course includes a family and a community focus including epidemiology. There is an elective 1-week ro- tation in an AHEC community as part of this course, in which the student

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262 PART II: PRACTICAL APPLICATIONS is expected tO perform a community diagnosis, becoming aware of the preceptor's practice as well as the health care and social services delivery systems that exist in that community. In the sophomore year, students are encouraged to participate in the Student Health Program, which is jointly funded and operated by the Colorado Health Department, the Colorado Migrant Council, and UCHSC. Students work with individual preceptors providing health care to migrant farm workers and their families in various areas of the state. This care is provided in private offices, schools, and health clinics. There is a brief curriculum that is presented to students focusing on the particular health problems of migrant farm workers, including the cultural and language barriers that frequently prevent adequate health care from being delivered. Junior medical students have multiple opportunities to receive their required clerkships (medicine, pediatrics, psychiatry, ob- stetrics-gynecology, and surgery) in community hospitals in the AHECs. As part of the senior year, a primary care clerkship is required of all students, which includes a curriculum segment of preventive medicine and com- munity oriented issues and is offered in the AHECs. The School of Nursing also offers COPC experiences through its tra- ditional community health nursing curriculum, undergraduate student AHEC rotations, and through a recently developed activity called Project GEN- ESIS. The latter consists of community studies by students and faculty focusing on what individual community leaders and townspeople believe are their health needs. These students analyze the existing health care delivery system and include social services, education, and religious net- works. A report is then prepared that is delivered to the community in a discussion session focusing on what should be done to implement individual recommendations. Although the AHEC projects and health professions schools in this coun- try can promote COPC, the real question is will they? To address this issue, the strengths and weaknesses of the COPC concept need to be examined. Strengths of this concept include the potential improvement of training to more adequately focus on real-world health problems, rather than the highly tertiary care issues that university faculty frequently study. Community oriented primary care training helps to assure the relevance of future prac- tice to community health problems. However, the COPC concept itself is not well focused with an organized advocacy group. Community oriented primary care means different things to different people and seems less likely to be successfully advanced in the bastions of medical educations with their feudal power systems than if a well-developed single concept existed that could be advocated by a strong group. In addition, faculties currently seem to have little incentive tO focus on COPC. Very few tangible rewards come as a result of dedication to primary care. Research support leading to pub-

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Can Area Health Education Centers Promote CORC? 263 lications, promotions, and tenure is focused in highly technical basic science and clinical areas. A disincentive on the practice side is the fact that private practitioners do not care to pay for the epidemiology that is necessary to assure that their practices are community-based. Without the incentive to have that work done, it is not being done in a structured way. Experience in Colorado suggests that, even in practices that have a family medicine information system (FMIS), the data in fact have very little influence on the services offered. Physicians use the FMIS primarily for billing purposes; the effect on the practice of the clinical data could not be seen. The arguments that COPC saves money appear not to be easily docu- mentable. For example, the costs of doing an epidemiologic study in the community are not offset by savings to the same pocket. The unit providing the epidemiology does not in fact realize the savings in lives or time lost from work. The latter accrue to someone else the employer or to the individual whose life is saved. The future of the COPC concept seems likely to rise or fall on the issue of financing. If public financing for medical care is reoriented to support the principles of COPC more fully than the highly technical, tertiary, ma- chine-oriented care that is provided for such things as heart transplant experimentation, kidney dialysis, etc., then COPC will grow and flourish. In the meantime, some focus needs to be brought to maintain the concept and continue its definition and advocacy in the various forums that help determine national health policy. It appears that the most likely source of immediate support for the continued development and propagation of COPC iS tO come, at least in the short term, from private funding sources.