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OCR for page 258
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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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.
Representative terms from entire chapter:
promote copc
