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The Beersheva Experience in COPC Ascher Segall, Carmi Margol's, and Moshe Prywes The School of Medicine of the Ben Gurion University of the Negev is located in Beersheva, the principal city in Israel's southernmost Negev region. Since its inception in 1974, one of its central commionents has been to improve the quality of health care in the region through an emphasis on physician training in community oriented primary care. The goals for both the undergraduate and postgraduate programs of medical studies reflect this approach. At the undergraduate level it is an- ticipated that a significant proportion of students will be motivated to ex- plore career pathways in primary care. In addition, irrespective of career choice, students will acquire sensitivity to the primary care dimension of medical practice in all its diversity, as well as basic general competencies in this domain. Goals for the postgraduate phase of physician training relate to the acquisition of more specific clinical, managerial, and epidemiologic competencies needed in the day-to-day operations of a community oriented primary care facility. Within the Beersheva context community oriented primary care is taken tO include: . facilitating entry of the patient into the health care system; . providing appropriate preventive and therapeutic health care services; . integrating and ensuring continuity of care through the various phases of illness; and . participating in outreach programs to serve the broader health needs of the population. 272

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The Beersheva Experience in COPC 273 Central to the process of curriculum development in Beersheva is a specification of competencies needed by practitioners in Israel to function effectively in each of the four domains of primary care. These were de- veloped through an analysis of physician performance. On the basis of the competencies identified, a set of educational objectives for undergraduate and postgraduate teaching in primary care was formulated. These compe- tency-based objectives, as revised from time to time, provide a framework for determining course content, selecting methods of instruction, and de- signing student evaluation for all courses that relate to primary care. Objectives for clinical teaching relate to the provision of comprehensive health care at successive stages in the natural history of disease within the resources and constraints of community-based ambulatory care facilities. The epidemiologic objectives are concerned with methods for quantitative assessment of community health problems and evaluation of the quality of health care. In the field management, educational objectives encompass those competencies needed in operating a community health clinic and in implementing public health measures. The curriculum components that relate to ambulatory medicine, epide- miology, sociomedical sciences, and management are designed to facilitate student attainment of these objectives. Instruction in these areas is inte- grated both horizontally within each phase of the curriculum and vertically over successive phases. Just as clinical studies in ambulatory care commence in the first year and continue until graduation, so basic sciences such as epidemiology and medical sociology are not confined to the early years of study. This "spiral" approach stresses the ongoing utilization of knowledge from the basic sciences to solve clinical or public health problems encoun- . . . tereu in community settlogs. During the first 2 years of the 6-year undergraduate curriculum, teaching of primary care takes place in a wide range of ambulatory health facilities throughout the Negev region. These include hospital outpatient clinics, primary care settings, occupational health units, rehabilitation facilities, and public health stations. Through direct experience students learn elementary skills such as patient/physician communication and develop basic capabilities in public health such as conducting a community health survey. Concom- itantly, through formal course work they acquire a knowledge base in clinical medicine, epidemiology, behavioral sciences, and management. In the third and fourth years selected disease models of high prevalence in the Negev are considered in the perspective of their natural history. This refers to a temporal continuum in the evolution of disability resulting from the disease process. Points along the time axis can be identified at which intervention may prevent the onset of the pathogenetic process, reverse it,

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274 PART II: PRACTICAL APPLICATIO NS or decreasee its rate of progression, thus reducing personal and social dis- ability. It is postulated that a balanced study of all phases of the natural history of disease results in a more realistic perception of primary care than does the traditional focus on episodic periods of hospitalization. This perspective emphasizes the acquisition of competencies in disease prevention and pa- tient rehabilitation, as well as in the provision of acute care. It underscores the responsibilities of the physician for participating in community health programs, in addition to providing personal health services, and provides a frame of reference for integrating clinic teaching with public health and management. Clerkships in community clinics during the fifth and sixth years complete the undergraduate program in primary care. Building on skills acquired earlier, students increase their competencies in both the clinical and public health dimensions of practice in a community setting. They function under direct instructor supervision in the fifth year and begin to assume limited autonomy and independent responsibility in the sixth year. Selected aspects of primary care are also taught as part of the hospital-based clerkships. This is accomplished in specialty outpatient clinics and through student partic- ipation in community outreach programs conducted by hospital-based de- partments. Continuity of training in primary care from undergraduate to postgrad- uate studies is a major concern of the medical school. The first class of medical students graduated in 1981. Two-thirds of the graduates have opted to participate in a Medical Graduates for Primary Care Program. This program affords graduates an opportunity tO practice primary care for 1 year, whether or not they intend to continue on to a career in this field. It is analogous to a primary care internship bridging undergraduate and post- graduate training. The young practitioner functions at a level of professional autonomy that is significantly higher than during undergraduate studies. On the other hand, a highly supportive environment is maintained to facilitate transition from the student role to that of practitioner with independent responsibility. To this end the full range of academic resources at the medical school are utilized. These include consultants in general practice and specialists who visit the community clinics regularly. Practice-related clinical problems are discussed at weekly sessions open to all participants in the program. Guidance in coping with administrative and managerial problems in the primary care clinics is also provided. For those graduates with longer-term commitments to primary care, a set of residency programs is being developed. The first to be implemented is a family practice residency that is currently training family practitioners

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The Beersheva Experience in COPC 275 to staff community clinics in the region. Primary care tracks within the internal medicine and pediatrics residency programs are beginning to train pediatricians and internists to function as consultants and, in some cases, . . . as primary care practitioners. At the beginning of this presentation the goals of what has come to be known as the "Beersheva Experiment" were described; recruitment and training of physicians in primary care and acquisition by all physicians, irrespective of career choice, of basic attitudes and skills related to com- munity oriented primary care. As increasing numbers of students complete successive stages of professional education in Beersheva, it will be possible to assess the extent to which these goals are met. Will the high proportion of Beersheva graduates opting to explore pos- sible careers in primary care be maintained beyond the first several classes? How many will remain in primary care? Does the distinctive curriculum in Beersheva make any difference in how graduates practice medicine? What is the impact of factors other than the educational experience such as per- sonal characteristics, family considerations, and professional or economic incentives? Answers to these and other outcome questions await the results of a long-term systematic follow-up of Beersheva graduates. In the interim there is ongoing process and short-term evaluation. This provides guidance in adapting the curriculum to changing needs while it continues to reflect the basic commitment of the Ben Gurion University of the Negev Medical School to community oriented primary care.