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Departments of Family Practice as Vehicles for Promoting COPC Thomas M. Melee and lack H. Medalie Case Western Reserve University School of Medicine in Cleveland, Ohio, under Dean Joseph Wearn, made medical history in the 1950s and 1960s by radically revamping its entire curriculum. Among the many innovations introduced were: . a strong student orientation with their participation in planning, pre- cepting, and evaluation, as well as self-educational facilities and initiative; an integrated carric~m; interdisciplinary subject committees; multidisciplinary labs; . beginning medical school with a live human contact (pregnant woman) rather than a cadaver; and . 7 months of electives in the final year and a required ambulatory clerkship. The view has been expressed that it was "the most significant develop- ment in medical education since the Flexner Report." Many medical schools since the 1960s have adapted aspects of the curriculum, while McMaster University in Canada and the University of Limburg at Maastricht in the Netherlands have gone even further in their integration. The spirit of readiness to try new ideas at Case Western Reserve University continued, and in 1974, under Dean Frederick C. Robbins, the faculty voted to create a department and discipline of family medicine that would have status equal to other departments. Today, the Department of Family Medicine (chairman, J. H. Medalie) 264

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Departments of Family Practice 265 consists of four clinical departments at university hospitals, the Cuyahoga County Hospital system, Fairview General Hospital, and Mount Sinai Hos- pital. Three of these hospitals have accredited residency training programs with 44 physicians in training. In addition, we have four Robert Wood Johnson fellows in training for an INS. (family medicine) program. The department also has three divisions based at the School of Medicine. These are: research, education, and family/behavioral science. The department is heavily involved in education of medical students, residents, postgraduates, faculty, and continuing medical education. The following illustrates the community orientation of the department. It provides a more detailed look at the activities of one of the clinical units, the Department of Family Practice at the Cuyahoga County Hospital system (director, T. M. Mettee). The department and residency training program are currently in their sixth year of operation at Cleveland Metropolitan General/Highland View Hospital the acute care/rehabilitative care hospital in the Cuyahoga County hospital system. The educational program derives much of its strength from itS affiliation with Case Western Reserve University's Department of Family Medicine described above. Special strengths in epidemiology, research, education, family sociology, family psychiatry, and community medicine have made major contributions to our community orientation and faculty development. A Health Resources Administration-sponsored training grant provided us with resources to establish a vital link with the Department of Medical Anthropology at Case Western Reserve University. This linkage put US in contact with J. Kevin Eckert, Ph.D., a medical anthropologist with a special interest in the urban elderly. Through his leadership a number of graduate students have carried out research in our target area, and we have hired one student, full-time, to coordinate and manage the activities of our com- munity outreach project (to be described later). These affiliations with university-based departments are without a doubt the key to our community oriented approach to service and education. The current challenge is to distill and synthesize information, concepts, and methods from the disci- plines represented by these affiliations, especially epidemiology and the behavioral sciences, in order to articulate practical approaches to community oriented primary care, which can be applied by the primary care practitioner, who usually functions without such university support. At the undergraduate level, our department and Family Practice Center serve as a site for elective Medical Apprenticeship Program (MAP) students (first and second year), who work in a patient care tutorial one-half day per week for 6 weeks with a resident, fellow, or faculty physician to gain exposure to a community responsive practice. The center also serves as a

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266 PART II: PRACTICAL APPLICATIO NS site for the required ambulatory/primary care clerkshipa 2-month rotation for fourth-year students. Unique features of that clerkship are: an in-depth family case study that includes a home and neighborhood assessment; and . a community project that is student-initiated and family physician/ anthropologist faculty-supervised, requiring data collection and resource ... . utilization in our target area community. One student community project surveyed target area industries, mapping the location of those work places and identifying all those considered "high health hazard" regardless of work force size. This proved to be an enlight- ening exercise, as it identified most hazardous work places as small (less than 50 employees) businesses some of which were located in residential neighborhoods. It also identified a lead smelter next to a playground, a low- income housing area, and the confluence of two interstate highways. Our awareness that these geographically intermingled sites might have produced an endemic lead poisoning situation caused us to plot geographically all the lead levels performed by the health department screening program. Our suspicion was confirmed, and subsequent education and interaction with the health department has occurred. Whether there is a cause and effect relationship between these environmental lead sources (highways and smelter) and toxic lead levels in these children remains to be seen. The fact remains that a student-initiated community project was responsible for making the . . assoclatlon. Another undergraduate activity, sponsored and supported by the Medical School Department of Family Medicine, is the summer fellowship program. Over the past three summers, one student has spent July and August assisting in a data collection process focused on community diagnosis. Their work has led to a multivariate factor analysis of our target area, a better understanding of the needs of the Hispanic community, and a method for screening patients for occupational illness. Our practice center services are now trying to adapt and become more community-responsive based upon this work. At the graduate level our Family Practice Residency Training Program focuses its recruitment on students with urban interests and community- responsive attitudes who are eager for community involvement and social change. Our practice center has identified a geographically bounded target area composed of 38 census tracts with a shortage of primary care health manpower. This provides us with a denominator population characterized as a multiethnic urban community of lower socioeconomic status. Our orientation program for new residents emphasizes community diagnosis,

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Departments of Family Practice 267 community resources, belief systems, explanatory models, home visits, in- dustrial survey and work place visitation, and target area exploration. A special feature of the department is a multidisciplinary study group of family physicians, residents, students, anthropologists, social workers, ep- idemiologists, sociologists, and family therapists all engaged, to various degrees, in a community outreach project. One of the major goals of this activity has been the study of concepts of community diagnosis as an ex- tension of individual and family diagnosis, i.e., viewing the community as a patient. We have reviewed community history and sought opinions from key informants, interest groups, political factions, local media, and individual citizens (including our own patients) in order to collect subjective data. Our community physical exam has been done on foot, in mini-buses, and in cars (often with a camera) to survey the geophysical environment and established . . . . community resources anc institutions. Census data, health department data, police records, and planning agency data were collected. With the use of census tract, geophysical, and lot line maps we have plotted much of this data in order to "see" our patient the ORGANIZATION OF CARE "POPULAR, FOLK, SELF HELP" EPIDEMIOLOGY'\ ~ ~ SCIENCE ~ 1~ ~ ~ . ORGANIZATION OF CARE "PROFESSIONAL" ~ Hi, I: :-:-:-:-:-:-:-:-:-:-:-: _~:- ................................................ ................................................ ............... -.-.- - -.-.-.-.-.-.-.-.- -.- ................................................ :~:: :~:~:~:~:~:~:~:~:~:~:~:. al lo en A I :-:-:-:-:-:-:-:-:-:-:-:-:-:-:-: - - - ~ ~ ~ ~ ~ ~ A _ .............. .' % ~ _ it, .............. ~ .-.-.-.-.-.-.-.-.-.-.-.-.-. . . . . . . . . . . . . . . . .-.-.-.-.-.-.-.-.-.-.-.-.-.~ ~ ........................................... ~ ' I. . . . . . . . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . . . . .# ` ' `-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-:-' BE L I E F SYSTEMS `-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-. _ _ `-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-' _ , `-.-.-.-.-.-.-.-.-.-.-.-.-.- -.-.-.-.-.-.-.-.-.-.-.-.-.-.-.-. - ; ---------.-.-.-.-.-.-.-:-.-.-.-.-.-.-.-.-.-.-.-.-.-' ~---------------------------------------------~ _: . ~ ~-.-.-.-.-.-.-.-.-.-.-.-.-.-.-----~ aim _ FIGURE 1 Community oriented primary care. EXPLANATORY MODELS

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268 ~ PART Il: PRACTICAL APPLICATIONS community- more clearly. Factor analysis has been a particularly helpful technique to reduce large quantities of information to a workable few without losing the power of our observations. Through this diagnostic proc- ess, we are developing a problem list and a small number of interventions or plans that we feel are "community-responsive." Another goal of this process is the development of a "community diagnostic tool kit" to be used by our residents in training and in their own communities after graduation. Hopefully, it can be adapted for use by any physician or health care worker committed tO community oriented primary care. In conclusion, our group has developed a Venn diagram that captures for us the concept of COPC (see Figurel).