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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

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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

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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.