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OCR for page 269
New Mexico's Primary
Care Curriculum
5. Scott Obenshain
Medical knowledge in the post-Flexnerian era has been expanding expo-
nentially. However, as knowledge expanded and tO assure that students be
exposed tO as much knowledge as possible, medical education has become
more lecture-centered. This has led to increasing dependence on rote mem-
orization as the means of learning. At the same time more and more of
our medical graduates are entering specialty training.
New Mexico established its medical school in the early sixties both to
provide its citizens opportunities for a medical education and as a means
of getting physicians to underserved areas in the state. In 1970 New Mexico
ranked forty-ninth in primary care physicians per capita, and the legislature
was getting restless.
In 1975 Arthur Kaufman and I began talking about the problem of
physician distribution both by specialty and geography. Based on Art's
experience with clinical electives in the first 2 years, which had been dem-
onstrated to improve students attitudes toward the basic sciences, we pro-
posed a curriculum track designed to select and educate physicians who
would locate in rural areas and be competent in providing primary care.
With the aid of both a planning and an implementation grant from the W.
K. Kellogg Foundation of Battle Creek, Michigan, we were able to start
the Primary Care Curriculum in the fall of 1979.
After reviewing the intellectual process used by medical students in the
traditional education programs and physicians in practice, and visiting a
number of different medical schools, including McMaster in Ontario, Sophie
Davis School of Biomedical Education at City University of New York,
269
OCR for page 270
270
PART II: PRACTICAL APPLICATIONS
and the physician assistant programs at Duke and Bowman Gray, we decided
to use educational methods that would mirror those techniques needed in
practice. The method chosen was a problem-based, learner-centered, small-
group tutorial format. The learner in this format must approach the clinical
patient problem, gather data, define problems, develop hypotheses as tO
the cause of the problem, formulate learning issues to assist in learning the
science basic to medicine, study these issues and return to the group to
further explore the problem, redefine the hypotheses, and then solve the
problem.
The curriculum is organized into two years of small-group problem-based
learning separated by a 6-month period of time in which the students
participate for a minimum of 16 weeks in a rural primary care clerkship.
This provides early primary care role modeling and is the students' first
clinical experiences. It gives them a proper perspective on the health care
system. In addition, the students are expected to continue the learning of
the science basic to medicine during this clerkship using the patients seen
as the problems from which to learn. Although the problem-based, learner-
centered approach combined with the early role modeling is unique in the
United States, the educational methods would be appropriate for the ed-
. . .
ucatlon of any practitioner.
Carl Rogers, in Freedfom to Learn, noted that "placing the student in direct
experiential confrontation with practical problems, social problems, ethical
and philosophical problems, personal issues and research problems is one
of the most effective modes of promoting learning."
Alfred North Whitehead also observed, in The Aims of Edification, that
'~your learning is useless to you till you have lost your textbooks, burnt
your lecture notes and forgotten the minutiae which you learnt by heart
for the examination.... The function of a university is to enable you tO
shed details in favor of principles."
The Primary Care Curriculum, which accepted its first class of 10 students
in August 1979, is a separate tract in the University of New Mexico School
of Medicine. These students were first admitted to medical school as part
of a class of 73 students. Once accepted, all students were asked to state
their preference for either the problem-based or the conventional track.
Those asking to be considered for the problem-based track were then
reinterviewed with noncognitive areas being considered most intensively.
These include geographic background, relevant community experience, so-
cioeconomic group, ability to work in groups, and desire for rural practice.
From these students the Primary Care Curriculum class was accepted. As
noted, 10 students were selected for the first class, 15 for the second, and
20 for the third and subsequent years.
In addition to the problem-based, self-directed learning around problems
OCR for page 271
Nex Mexico's Primary Care Cz~rriculum
271
the students do in the first year, they are also taught basic clinical skills
necessary for acquiring a data base from patients. This includes history
taking and physical examination skills, as well as elementary laboratory
procedures, such as a blood smear, urinalysis, and basic cultures. With these
the students are ready for their rural clerkship.
During the clerkship the students are expected to see patients under
supervision and tO define their own learning needs from these patients. To
assist the students in understanding the patient's role as a member of a
community, each student is expected to design and carry out a community
project. The project is designed to assist the student in learning to apply
skills in study design, patient education, epidemiology, and data collection.
Projects to date have included study of horse-related injuries, both occu-
pational and recreational; a longitudinal study of Navajo women with Class
II dysplastic Papanicouau smear; attitudes of minority mothers with mentally
retarded children; and a study of attitudes toward breast feeding in a pre-
dominately Hispanic community.
While the students are participating in their rural clerkships, faculty from
the medical school visit the site regularly to assist the students and their
. . . . . , · ~ .. . . .
preceptors in maintaining t nelr learning. 1 nese VlSltS may lnvo .ve reviewing
the students' learning issues and assisting in smoothing the preceptor-stu-
dent interaction around learning, since for many preceptors this style of
learning for medical students is a new experience.
For the first class of to students, 8 felt the experience strengthened their
desire for a rural primary care practice, l was unsure, and l felt a rural
specialty practice may be more to his liking. These feelings have tended to
hold up through the third year, with 7 still planning careers in primary care
, . .
mealclne.
The Primary Care Curriculum is designed to select and educate physicians
who will locate in a rural underserved area and be competent providing
primary care. The methods employed were chosen to enhance the student's
ability tO solve patients' problems and to assist the student in learning how
to learn so he will be a lifelong learner. The provision of appropriate role
models early in the student's experience should assist the student in being
able to chose such a career after having worked with a physician who had
chosen rural primary care as his life work. By encouraging the students to
look carefully at a community problem, it is hoped they will learn tO apply
those skills to their future practice, thereby practicing in a community
oriented fashion.
Representative terms from entire chapter:
rural primary
