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Chapter 6 INFUS ION OF NEW FIELDS INTO MEDICAL EDUCATION Barbara Filner, Victoria Weisfeld, and Delores L. Parron When is new information ripe for insertion into the medical education process? If the information is the result of ongoing programs of research in well-established health sciences disciplines, such as biochemistry, endocrinology, or cardiology, the decision is generally left to the discretion of the individuals directly responsible for transmitting the body of knowledge in that area, either through lectures or by clinical example. However, when the new information is in itself a new field or a major shift in concept, decisions require more comprehensive thinking. They must be made in the context of the entire content of knowledge to be transmitted to physicians in training, and they must take into account the time and resources available for that education process. In the last decade or so, there have been pressures to incorporate formally into medical education such topics as human sexuality and death and dying. More recently, attention has been called to the need to educate physicians in such areas as health promotion, aging, behavior and health, nutrition, health policy, costs of health care, and legal and ethical issues in medical decision making. Undoubtedly, in the next few decades other significant areas will emerge or be recognized. Each topic has its unique strengths and constraints, but certain generic questions arise time and again, including the following: 1. Should the material be presented in a course by itself, or should it be integrated into the content of established courses ? 2. Should responsibility for the subject area be vested in a new department, in a division of an established department, or in individual faculty members dispersed through many departments? 3. Should the material be required or elective? 4. Should there be a residency program in the area, with or without a recognized specialty (or subspecialty) status? 5. How can adequate recognition of the subject area be attained in standardized exams, such as that of the National Board of Medical Examiners? 6. What setting for clinical experience is the most appropriate for transmitting the practical patient care aspects of the subject area? 148

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7. Despite apparent need, and a number of well-reasoned reports over the years urging attention to the subject (for example, in the 1930s, 1950s, and 1960s in the case of preventive medicine ) , these subjects receive only minimal recognition in medical education. perhaps the most important question is, who must be convinced?] Is it the responsibility of medical education to sensitize and orient students to these areas? Aging, ethics, and the like depart considers bly f ram the biomedical model of medicine . For example, much of health promotion involves patient education; much of the thrust of heal th care f or the elderly involves maintenance of the maximal amount of functional independence--and this may involve such social services as Transportation or homemaker services. In the 1981 Presidential Address of the Association of American Physicians, Dr. Donald Selden2 said: Medicine is a very narrow discipline. Its goals may be defined as the relief of pain, the prevention of disability, and the postponement of death by the application of the theoretical knowledge incorporated in medical science to individual patients. In contrast, Abraham Flexner3 wrote in 1910 that The physician's function is fast becoming social and preventive, rather than individual and curative. Upon him society relies to ascertain, and through measures essentially educational to enforce, the conditions that prevent disease and make positively for physical and moral well-being. In addition to honest disagreement about what medicine (and medical education) is and should be, there are other barriers to full recognition of less biomedically oriented subject areas. Financial pressures are such that deans, department chairs, and hospital administrators not unreasonably favor those disciplines that can bring in money--either through research grants or through income-producing (reimbursable) patient care. The knowledge base is neither as firm nor growing as fast as that for traditional laboratory-based biomedical sciences. Also, departments and faculty members are reluctant to give up any of their time in the curriculum, in part because hours are a reflection of status. Despite the comfort of the status quo and the problems cited above,-there has been innovation in medical education, and the "orphan disciplines" have achieved some recognition. To further elucidate factors to be considered, and the forces driving decision making, this chapter presents three case studies: (1) aging in medical education; (2) behavioral sciences in medical education; and (3) health promotion and disease prevention in medical education. 149

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Aging in Medical Education It is well documented that the number and proportion of elderly persons (age 65 and over) in the United States are increasing, that they require a disproportionately large share of health care services, and that there are features of care of the aged that call for the application of special knowledge, skills, and attitudes by all physicians.4-6 Regardless of socioeconomic status, sex, or geographic location in the United States, the majority of elderly persons (60 to 80 percents report themselves to be in good or excellent health. 7-8 This stems from two factors: (1) there are numerous physiologic changes with age, but these are not synonymous with ill health, which stems from disease rather than from these changes; and (2) the majority of elderly persons underreact to serious symptoms or accept them as inevitable consequences of age. Thus, many elderly are quite healthy, but those who are ill come to the regular attention of physicians only late in the development of disease.4 In addition to late presentation, the pattern of illness for the elderly differs from that of younger people . Acute illness is less frequent, but when it does occur, more restricted activity-days result.9 Older patients are likely to have multiple chronic problems. In addition, presentation of common disease is more likely to be atypical (apathetic hyperthyroidism, silent MI, afebrile pneumonia, less fulminating lymphatic leukemia and breast cancer, but accelerated course for thyroid carcinoma).4 Management of care of the elderly requires special knowledge. Age-associated impairment in hearing, mobility, and speed of retrieval from memory complicate history taking, physical examination, and subsequent compliance with treatment regimens. Changes in enzyme and organ function, multiple prescriptions (often from different doctors), and memory def icits combine to require special care in pharmacotherapy. (In addition, drug-induced illness mimics the stereotype of old age--absentmindedness, apathy, confusion, tremor, anorexia, and anxiety.) Finally, physicians often are the gatekeepers for community health and social services, including rehabilitation centers, day hospitals, hospices, housekeeping and home health services, in addition to acute care hospitals and skilled nursing facilities. Referral to transportation services also can be critical to the mental and physical well-being of elderly patients. Accordingly, an Institute of Medicine (IOM) Committee on Aging and Medical Education concluded that "care of the aged calls for application by the physician of some special knowledge, skills, and attitudes" and that there is a body of knowledge in aging and the problems of the aged that is relevant to medical education. It consists of information concerning a) the biological, behavioral, and social changes that are a normal 150

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concomitant of aging; by the role of these changes in producing functional impairments or in making the individual more vulnerable to environmental factors leading to specific diseases; and c ~ the health care and social resources most necessary for managing the problems of the aged. Although these areas of information are of special importance to the care of the aged and to research on aging, they do not represent a clearly separable and unique discipline, but are part of all the biological, behavioral, social, and clinical sciences.4 The committee further concluded that these aspects of physician competence should receive appropriate emphasis throughout medical education and in the accreditation and certification procedures; that substantial improvements in teaching about the process of aging and problems of the aged are required at all levels of medical education; and that new opportunities exist for the development of knowledge in aging, but the amount of funding available for research and training appears to be a limiting factor.4 More recently, the Association of American Medical Colleges (AAMC) Steering Committee on Undergraduate Medical Education Preparation for Improved Geriatric Carel suggested the following responsibilities for medical schools: o to provide a focus for increased attention to aging; to establish a faculty group interested in gerontology and geriatrics ; o to expand research in aging; and 0 to offer a variety of clinical settings in which students experience the care , diagnosis, and treatment of the elderly ; to have medical students interact with healthy, independent elderly persons. Recent Trends in Education on Aging Medical School One of the early attempts to assess aging in medical school curricula was a review of 99 medical school catalogs for 1969.11 "Geriatrics," "gerontology," "senescence," "senility," or "aging" appeared in 124 course descriptions of 48 schools. Seventeen schools had affiliations with institutions engaged in aging research or care of the aged, and there was a total of 15 specific geriatric or gerontology faculty positions. In the years 1978 to 1981, the number of U. S . medical schools of fering courses in "geriatrics" increased steadily from 51 to 82.12 In 1982, Robbins and Beck identified 133 programs in aging at U.S. medical schools.l3 In 1978, half of the courses related to aging were in geriatric psychiatry, gerontology, and the behavioral and community aspects of aging. Almost all were 2- to 4-week elective courses, with low 151

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enrollment. In a few schools, a two-week period in a required course, such as family practice clerkship, was devoted to aging. Two freestanding, required courses were identified. In addition, seven schools had required and 22 had elective rotations in nursing homes.4 The IOM Committee on Aging in Medical Education recommended "that medical schools include appropriate content on aging in basic and clinical science courses " and " the establishment of a complementary required course that integrates knowledge about aging and the problems of the elderly."4 The AAMC endorsed the first of these recommendations, but did not specifically suggest an integrative course .10 Surveys conducted in the late 1960s and early 1970s showed that interest in geriatrics and gerontology diminishes over the four-year medical school period,*14~1 but that positive attitudes can be fostered by respected faculty role models.16~17 As a result of the growing realization of the significance of health care for the elderly, and the expanding knowledge bases, there may now be more widespread and sustained interest among medical students. There have been some interesting innovations in teaching about aging, as exemplified by the two programs described in the 1978 Institute of Medicine report.4 1. George Washington University Medical School's program spans four years and is integrated with house staff, nursing, and social work programs. Basic science courses stress gerontologic content; "Issues in Health Care," a required course, covers diagnostic and therapeutic problems of the elderly and a team approach to their care; the required primary care clerkship includes four hours per week in a nursing home. Medicine, gynecology, and surgery have grand rounds on aging at least once a year, and this is even more frequent for psychiatry and primary care. There are numerous 4- to 6-week electives on aging for fourth-year students. 2.- The University of Florida uses the primary care program as a basis for teaching geriatric medicine. Emphasis is placed on ambulatory care, the incorporation of other professionals in the health care team, the use of community resources, and reliance on behavioral sciences to facilitate adherence to treatment regimens. Continuity of care allows observation of clinical progression in the aged, often not demonstrable during short rotations. However, few of these programs have succeeded in producing researchers or fellows--the future faculty and leaders in the field of * Attributed to such factors as time pressures from other subjects, less satisfaction in dealing with chronic and intractable problems, slow rates of information gain from research, and negative attitudes on the part of faculty and residents. 152

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aging 1 One critical element in establishing a strong, research- oriented program that is successful educationally as well, is a critical mass of faculty (perhaps 10 to 12) with sufficient support for research and teaching activities and a commitment to both. It is important to have a minimum nucleus of three or four researchers together in one department (e.g., medicine); others might be located in psychiatry, pharmacology, and other basic science departments. There also must be appropriate and high quality clinical settings to provide teaching opportunities.] Because the structure and placement of courses in geriatrics and gerontology would depend upon the organizational and educational philosophy of individual schools and because many of the teachers needed for such a course are already members of medical school faculties, a principal task is to develop consensus on the importance of the subject matter and then to assure that primary responsibility is assumed for teaching it. This could be accomplished in a variety of ways including a department, a division of a department, or an interdepartmental steering committee.4~18 With regard to clinical clerkships for advanced medical students, the IOM committee recommended training in multidisciplinary settings of care, with nursing, social work, and rehabilitative specialty staff, and where other specialist consultants are available. There should be experience in nursing homes and other long-term care facilities, and with home health programs and other alternatives to institutionalization.4 Graduate Medical Education In 1978, the TOM Committee on Aging . and Medical Education recommended against the establishment of a formal practice specialty in geriatrics, but favors the recognition of gerontology and geriatrics as academic disciplines within the relevant medical specialties. The committee agrees with the American Geriatrics Society and other groups that have recommended against a board-certified specialty. It believes that the care of the aged should be the responsibility of appropriately trained primary care physicians. . . . The committee is aware, however, that development and recognition of geriatrics within various disciplines is necessary to advance research and education in aging and to train leaders in the field. Precedents include such disciplines as clinical pharmacology and genetics, which have remained as areas of concentration for a--small number of facuty members, rather than becoming specialties or subspecialties with board certification.4 Recently, a Delphi process was undertaken for the Veterans Administration to identify essential components of graduate training.l3 Recommendations were made regarding training in geriatrics if it were a specialty and for training as part of other specialties (internal medicine, family practice, neurology, and 153

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psychiatry). The guidelines agreed upon were intended to allow flexibility and innovation but to assure a high standard of professionalism, in the absence of a certifying body, for the 44 graduate medical education programs in geriatrics identified in the United Stalls. (There also are 36 geriatric fellowship programs.) Barriers to Progress It is apparent that in the past five years there has been much growth in the f ield and active discussion of the generic questions raised in the introduction to this chapter. There is strong consensus among those in the f ield that inf ormation on aging should be integrated into the medical education process through the adaptation of numerous core courses. There also is strong consensus that experience in a variety of clinical settings, including acquaintance with the healthy elderly, is essential to a balanced view of the health care needs of the elderly. Most reports tentatively conclude that a department or specialty in geriatrics is not essential, but avoid a firm judgment until further experience is gained. Various alternative approaches are suggested to provide instructional and research focus. What of acceptance of the importance of knowledge of aging outside the field? The increase in identifiable courses and in research funds suggests considerable progress. Barriers that remain include "ageism" , a knowledge base that is growing, but that remains descriptive to a great extent; an emphasis on high technology in teaching hospitals; academic recognition going most readily to narrow specialty research rather than to the interdisciplinary research appropriate to studies of aging; a relatively modest pool of research funds relative to other disciplines; and a reimbursement system this focuses on acute care and that is a non-system for long-term care. Behavioral Sciences in Medical Education Studies of the burden of illness in affluent, industrialized nations such as the Uni ted States and Canada document that the prof lie of illness, early death, and related long-term disability have major behavioral components.20 Patterns of behavior often referred to as lifestyle account for as much as 50 percent of mortality from the 10 leading causes of death in the United States.21 Behavioral factors such as heavy cigarette smoking, excessive use of alcohol, and high risk-taking are important in the etiology and pathogenesis of cardiovascular diseases, cancers, respiratory diseases, and accidents, for example. The need for all physicians to learn the basics of psychiatry is suggested by recent epidemiological findings that, at any one time, about 15 percent of Americans suffer from some form of mental 154

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disorder, and 54 percent of identifiably disordered individuals are seen only in the ambulatory, general health care sector. The limitations of specialty mental health resources would make it difficult for the mental health sector to absorb the high numbers of patients with mental disorders being seen in the general health care sector. Furthermore, a great many patients have significant emotional or behavioral problems expressed as somatic symptoms or personal distress. The onset of physical illness often is precipitated by psychosocial stress or elicits maladaptive behavioral responses.22 Failure to recognize a correlation of physical and behavioral factors can impair the restoration of the patient to health. The behavioral sciences also provide invaluable insight into the interview process, the cornerstone of medical diagnosis. Not only should communication skills be enhanced by this knowledge base, but also to be enhanced are such essentials as listening and counseling skills, observing signs of emotional distress, assessing community and f amity support, and recognizing the impact of cultural and social factors on patient beliefs, expectations, and responses. Research into the mental health skills of family physicians reveals specific inadequacies of the education system. For example, although many primary care physicians make accurate assessments about emotional disorder, many others do not. Furthermore, inadequate training in counseling skills is the rule rather than the exception, and inappropriate prescription of psychotropics appears to be widespread. Recent Trends in Education on the Behavioral Sciences For the most part, departments of psychiatry and behavioral science, staffed by psychiatrists, psychologists, social workers, and other behavioral scientists, have been responsible for helping medical students acquire insight into interview techniques, knowledge of the diagnosis and treatment of mental disorder, and an appreciation for the intimate interplay of behavior, soctocultural factors, and physical health. While a major responsibility of psychiatry can be defined as teaching about the mental health needs of individual patients, it also includes a responsibility for teaching future physicians about their own mental health needs, and for helping to prepare them to deal with sickness, death, and dying--especially in regard to the phynician's own limitations. As in many other areas of science, development of behavioral sciences was stimulated by identification of significant possibility for progress coupled to availability of funds. Funds earmarked to promote behavioral sciences teaching in the medical schools began to appear in the 1950s from both public (e.g., National Institute of Mental Health, National Institute for Child Health and Human Development) and private sources (e.g., Russell Sage Foundation, Josiah Macy Jr. Foundation). Some schools developed departments of behavioral science, usually within the basic science framework, but 155

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for the most part these funds settled in departments of psychiatry, many of which became retitled "Department of Psychiatry and Behavioral Sciences." Some departments of pediatrics, family practice or primary care, and community health/preventive medicine also have a significant history of employing biobehavioral scientists in their teaching programs and attracting the necessary funding to support them. With recent advances, particularly in the neurosciences, the advocates of biobehavioral science's role have become more persuasive. Resistance has begun to shift and at least some consensus for change is appearing to develop. Most medical schools include behavioral science content in their educational programs and some schools have divisions or even departments of behavioral sciences. A January 1980 mail survey on the organizational structure for behavioral sciences teaching in U.S. medical schools elicited 90 responses.24 The most frequent structure was a single department (46 schools); 34 schools were multidepartmental, and 10 had a matrix organization. Overall, participation of 43 dif ferent departments was indicated, with psychiatry being the most common. According to the authors, the overall f indings suggest that the optimal, preferred, and most frequent form of organizational structure for teaching behavioral science in American medical schools is a unidepartmental structure within which a wide diversity of disciplines are represented. . . . There was little evidence of any strong sentiment toward better integration of multidepartmental efforts; if anything, the tendency was to express needs in the direction of increased autonomy. The organizational advantages of unidepartmental structures included clear leadership, defined responsibility, and strong faculty morale. The educational advantages included coordination, integration, and lack of duplication. The advantages of the integrated multidepartmental or matrix structures appeared to be mainly educational. There was greater scope for flexibility, variability, and innovation, but there were obvious organizational problems in control and coordination.24 The National Board of Medical Examiners (NBME) has reflected these developments by including questions on the sub ject in its Part I (preclinical) examination since 1972. Despite these developments, many medical educators have continued to raise questions about the relevant content for student learning in behavioral sciences as well as to note the lack of objectifiable goals associated with the learning process. Four areas will need to be carefully considered to ensure integration of psychiatric/behavioral sciences content in medical education and training: (1) revising the content of the standard medical school curriculum, in terms of both orientation and 156

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instruction in specific skills; (2) offering more appropriate clinical training experiences to prepare medical students and residents for the practice of integrated health/mental health care; (3) providing appropriate and effective role models throughout the educational and training process; and (4) upgrading continuing education for practicing physicians. Content Education and training of medical practitioners should l include knowledge from many disciplines that are not necessarily considered medical, including psychiatry. Social and behavioral science fields such as anthropology, economics, psychology, and sociology should contribute to both premedical and medical school curricula. One of the goals of medical education is not that the content of all basic science knowledge be retained in its disciplinary form by the practicing physician, but rather that it be integrated and remembered in the context of specific clinical problems of patient care and mechanisms of disease. Since the expression of human behavior occurs at the interface between the internal (physiological) environment and the external (sociocultural) environment, and since some change in behavior is usually involved in biological and social dysfunction, the teaching of behavioral science can become an effective integrative medium for the various disciplinary perspectives in medicine. One method that has proved effective is to use case examples that relate to immediate clinical practice of medicine--the main purpose of including this content in the curriculum. Although the modern trend in medical education has been in the direction of promoting a more flexible, less biotechnical orientation and approach among health care providers, the teaching of behaviorally oriented content must include instruction in the specific mental health aspects of patients' problems. For example, three related types of skills are needed: (1) detection of mental health problems; (2) accurate assessment and diagnosis of those problems; and (3) appropriate management of them, which requires both an understanding of psychotherapeutic techniques--counseling and medication--and of when to make appropriate referrals. The behavioral science content is found in association with extensions of traditional bodies of knowledge in the curriculum and also as distinctly new areas of content. It is clear that some of this content is being grafted onto the teaching in the areas of growth and development, physical diagnosis, interviewing and case history, epidemiology, biostatistics, psychiatry, neurosciences, pediatrics, family medicine, history of medicine, medical care, legal medicine, preventive medicine, and community medicine. Content areas that have been included in this way are (1) health beliefs model and (2) interpersonal skills and organizational behavior. In general, the behavioral sciences and psychiatry content in the medical curriculum reflects or in some way resembles areas identified in the content outlines of the National Board Examination.25 Clinical Training Effective application of skills requires practical experience. Even when students are or can be motivated to become providers of integrated health and mental health care, most 157

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training programs do not furnish adequate clinical preparation for the practice of mental health care in general health care settings. Because most medical students do not choose to specialize in psychiatry, practical experience in applying mental health skills under supervision has been limited for the most part to the psychiatric rotation as a small and discrete part rather than as an ongoing process of medical education. To promote effective integration of mental health and general health care, training of all potential medical care providers-- including those specializing in psychiatry--should be available and encouraged in integrated care settings, such as neighborhood health centers, continuing clinics, and other primary care settings that include mental health services. Students should be integrated into primary care teams with psychiatric social workers, nurse practitioners, staff physicians, and the like to encourage sharing of skills and responsibilities. Traditional hospital-based training programs provide very limited opportunities for students to learn how to establish the longer-tenm relationships in which health and mental health care most successfully are combined. Linking such academic centers with various community care systems has been suggested as an effective way to provide training in integrated care.26 Role Models While there is progress toward integrating behavioral _ sciences content in the preclinical years, the utility of this information seems to begin to fade in importance in the clinical years, during which teaching is largely at the bedside by senior, attending physicians. Among this group, there does not yet seem to be a "critical mass" of physicians who believe in and can practice integrated care in order to demonstrate commitment to health/behavior linkages at all levels of care. Health sciences faculty, particularly physicians, with a grasp of this concept must be recruited and nurtured so that students observe application of behavioral sciences principles in the practice of medicine. Continuing Education The rapid expansion of science makes it impossible for physicians to absorb sufficient information within the standard six to eight years of training. Continuing education programs will become even more important than they are now. These programs cannot afford to remain the rather ad hoc, drug-company- sponsored exercises that they have been. Some attention must be given to quality control of these programs. One benefit of such experiences can be in recruiting--from the ranks of physicians who participate in them--faculty role models who can demonstrate in their practice the relevance of biobehavioral sciences. Barriers to Progress Ei senberg and Kleinman30 suggest that the key task for medicine is not to diminish the role of the biological sciences in the theory and practice of medicine but to supplement it with an equal application of 158

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Some educators believe that students retain more information when it is linked with the care of patients, even in the preclinical years, and therefore support participatory, rather than passive, learning or reading in preparing a preventive medicine curriculum. 43 Clinical correlation conferences conducted in basic science courses are one mode of introducing preventive issues, and such mergers are "limited only by the interest--and the creativity--of the faculty."44 The case study approach as a primary teaching method for preventive medicine has received considerable support. Epidemiology and biostatistics (as well as other basic sciences) have been successf ully taught through the case method at ~IcMaster University in Hamilton, Ontario.45 (See Chapter 5. ~ The curriculum's underlying assumption with regard to epidemiology and biostatistics is that they must be integrated with the other basic and clinical sciences. Clinical training provides the opportunity to address the behavioral components of a prevention strategy, enabling physicians to place it "in a biological and a psychosocial context."46 Included are basic clinical skills in screening, history taking (noting occupational histories and identification of exposures to environmental hazards), examination and assessment, verbal and nonverbal communications, and counseling and behavior modification. Awareness of the availability of other health services and community resources and of when and how to use them is essential.39 Regardless of specialty, all physicians have opportunities to engage in preventive activities, and need to have the knowledge, skills, and attitudes required to practice prevention in their particular field of expertise. Preventive Medicine Residency Programs Four areas of special concentration have developed within the preventive medicine specialty: aerospace medicine, general preventive medicine, occupational medicine, and, of longest standing, public health. Physicians can obtain certification from the American Board of Preventive Medicine (ABPM) in one or more of these four areas, but not in the overall field. Graduate medical education in preventive medicine is structured similarly in all four concentration areas, consisting generally of a clinical year, an academic year, and a field year. Usually, the clinical year involves direct patient-care training in a residency program sponsored either by one of the clinical specialties or by preventive medicine. Many programs use a year of hospital-based clinical specialty training to satisfy the clinical-year requirement. The number.of programs offering the clinical residency year is small, and such programs as are offered appear relatively unpopular. A survey of preventive medicine residency program directors found that only 35.6 percent believed that preventive medicine faculty had significant input in the clinical training year. 47 The academic year usually leads to a master of public health degree or its equivalent. The field year is most often conducted in a setting 164

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appropriate to the particular concentration area. Residency programs, therefore, are found in health agencies, medical schools, schools of public health, corporations, and military settings. In its 1980 survey of preventive medicine residency programs, the American College of Preventive Medicine identified 68 active U.S. programs in public health, general preventive medicine, and occupational health; these programs included clinical, academic, or field-year training, offering 652 resident positions.48 However, only 53 percent of the positions were occupied. All three years in the programs have fewer residents in training than their maximum capacity would allow. The proportion of funded residencies that are filled, however, is much higher (75 to 85 percent). The small number of funded residency programs in prevention* is frequently decried; yet, it is interesting to note that 15 to 25 percent of the funded positions remain unfilled, and a few schools attract residents to unfunded programs. The low numbers of residents completing programs is partially accounted for by the multiple-year structure of the residencies and the newness of some of the programs, particularly in occupational health. Great variability has developed in the content of the clinical and academic years of preventive medicine residency programs, as schools have followed their historical course. The diversity of sites for the field year ensures that it, too, varies widely among programs. Continuing Medical Education Education in health promotion and disease prevention is considered to have an appropriate place in continuing medical education programs. The need for such programs is heightened because of the propensity for midcareer physicians to shift to a prevention-oriented practice. Barriers to Progress A number of issues whose resolution is prerequisite to more effective prevention education and the barriers to greater efforts in promotion and prevention are discussed in this section. Some of these result from factors in medical education, some from conditions of medical practice. Reimbursement disincentives constitute a significant barrier in both educational and practice settings. A practice based solely on prevention is fiscally impractical.3 The mix of preventive and diagnostic-and-curative activities that future physicians undertake may tend to shift even further toward the latter, unless there are radical changes in reimbursement policies. *For example, in 1980/81, the University of California sponsored 4,475 medical residency programs, mostly from university funds, none of which was allotted for preventive medicine or public health.40 165

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A recurrent theme of the 1980 national symposium on "Prevention and Medical Practice: The Role of Undergraduate Medical Education," was the need "to teach medical students how to think."49 Epidemiological and biostatistical training, as a way of approaching problems, provide one means for "teaching thinking, " just as does grounding in the scientif ic me thod . Students also need to know specif ic skills (some of which are yet to be identif fed or systematized ~ that will enable them to practice preventive medicine and apply its principles. "It is the lack of specificity, the lack of opportunity to demonstrate exactly what one means in these prescriptions (to exercise or 'relax') that may be associated with the lack of efficacy of physician-provided preventive services. 36 To overcome this historical lack of specificity, several attempts at developing preventive medicine curricula have been made.50 The range of possible medical school curricula changes that would incorporate more prevention material includes (1) giving more teaching time to departments of preventive medicine , ~ 2 ~ integrating prevention into teaching of other disciplines, and (3 ~ starting over. The divisiveness and turf-guarding of medical school departments militate against allotting more time for teaching that originates in departments of preventive medicine, particularly given the usually low organizational status of such departments. A more feasible strategy may be to integrate prevention content into existing courses, as an "extension of teaching" in various disciplines. Current trends and experiments that would foster competency-based medical school curricula would seem to enhance the prospects for teaching prevention. A competency-based curriculum is developed with a clear notion of the kinds of medical practitioners the educational system is intended to produce. Its teaching objectives can be designed to include the knowledge, skills, and attitudes essential to prevention, as demonstrated by the American College of Teachers of Preventive Medicine competency-based prevention curriculum. Broadly defined objectives could break the grip on curriculum held by the medical school departments, which now set the standards for their own areas of teaching, then battle with other departments for teaching time. "Major curricular reforms seem distant as long as educational needs are persistently defined in terms of how much of a given discipline a student should know.''51 Discussion of educational objectives leads naturally to the matter of student evaluation. Some experts have urged a greater proportion of prevention-related material on the Federal Licensing Examination of the National Board of Medical Examiners as an incentive for medical students to take this topic seriously.39 (Certification bodies in relevant specialties could do the same. ~ Despite some prevention content in.the FLEX examination, it is not deemed sufficient; nor are other evaluation tools in use that pertain to this area.44 Satisfactory performance on prevention content is not now linked to academic progress in medical school. Two testing weaknesses specif ically germane to prevention-oriented pract ices are that (1 ) prevention requires considerable integration of 166

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biological, psychosocial, environmental, and other knowledge--a complexity that multiple-choice questions cannot possibly reflect; and ~ 2 ~ they do not assess well a signif leant component of what medical students need to acquire regarding prevention--namely, attitudes. Means for evaluating attitudes are available, 51 but they are not paper-and-pencil tes t s . Mo st clinical instruction takes place in hospitals--not particularly good places for education about prevention. Some experts believe, however, that preventive principles can be taught effectively in the inpatient setting, after the acute crisis has passed, through consideration of what might have been done to prevent the illness at hand, or by capitalizing on family members' receptivity to interventions that may prevent future crises.44 Others believe equally strongly that prevention teaching can occur only in settings intended for that purpose and that its success depends on the availabili ty of appropriate clinical settings oriented toward modeling such care. The availability and attractiveness of such special settings is problematic. Financial and attitudinal problems also attend efforts to increase the prevention component of postgraduate medical training. The costs of training residents in prevention are difficult to recover from fees charged . Prevent ive medicine is "time-related rather than technology-related," and "a department not generating income at a rate comparable to others is likely to be the first to feel the effects of budgetary cutbacks in the medical school."52 This problem has been recognized by the American College of Preventive Medicine, which permits the clinical year of its residency training to be conducted under the auspices of other teaching departments, usually a primary care specialty. Meeting the costs of teaching in such ambulatory-care-based specialties as family medicine, general pediatrics, and others, remains a major dilemma. Costs of inpatient clerkships disappear into the total hospital bill and to date are covered by third-party payers; ambulatory care, which is expensive for hospitals to provide, is less often covered by public and private insurance.53 In 1979/80, principal sources of funds for a sample of general preventive medicine residency programs were university general funds (38.1 percent), federal government programs (36.4 percent), and state general funds (38.1 percent).54 Public health residency programs were funded primarily by states (75.4 percent) and the U.S. Public Health Service (16.5 percent). The number of programs involved is not large, however. Many cannot reconstruct their budgets because their residency programs are linked to other programs or are part of a departmental budget, which could denote either integration or lack of control and accountability. Resident, clinician, and faculty role models of prevention-oriented care-givers, now few and far between, are sorely needed. Instead, in their clinical training, students often confront negative attitudes toward prevention from both faculty and residents. In one opinion, "the most powerful negative factor in the teaching of prevention in 167

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the clinical years is the attitude of the resident on the floor, the students' most available role model. "53 Attitudes hostile to prevention (or ambivalent at best) obviously were learned from the previous generation of residents. Breaking the cycle requires a high degree of awareness and the availability of attractive alternative educational opportunities, such as community clerkships. Developing such alternatives acknowledges that attempts to instill prevention-oriented thinking in the inpatient setting will most likely be sacrificed to the exigencies of acute care. In the hospital, the slower pace and seemingly routine components of prevention make it seem "boring," and the lack of immediate (or near-term) response to physician interventions makes it seem unrewarding. Much has been said about the need to strengthen the data base relating to health promotion and disease prevention.55 A sounder, research-based body of prevention knowledge not only would benefit patients and public, but would also make the field more palatable to "hard-science" medical educators. Particularly in health promotion, and particularly in the behavioral area, prevention suffers from the lack of status and lack of specifics that at f lict the behavioral sciences generally. Summary and Recommendations on Promotion and Prevention Ma jar conclusions and recommendations on the teaching of heal th promotion and disease prevention are: 1. A body of knowledge, skills, and attitudes f or prevention does exist. It is solid in the middle, but increasingly indistinct as the margins are approached. Where specific prevention skills and techniques are available, they should be taught at some stage (or several stages) of the medical education continuum, including in continuing medical education. Where these do not exist, they need to be developed, defined, and validated through research. 2. Research on prevention requires a major commitment of new resources and imagination. 3. The attitudinal dimension of preventive teaching is critical. Although attitudes are often neglected, some innovative teaching programs and evaluation tools have been developed. One of the attitudes taught should be to hold realistic expectations of the results of behavioral interventions. (Results can be predicted more accurately and intervention methodologies improved through research.) 4. The place of prevention in medical education and practice should be evaluated with the broad health needs of society in mind, taking into account such factors as the increasing proportion of elderly, the needs of the population to adapt to rapid technologic change (involving exposure to new and diverse environmental hazards and stress), and the lost opportunities represented by each case of preventable chronic disease and injury. 168

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5. No serious national educational effort will take place until the problem of reimbursement is resolved. The present blanket exclusion of preventive services from federal health insurance programs is not responsive to the current state of knowledge, limited though it is, about the effectiveness of preventive efforts. Research to clarify reimbursement issues is needed, and research to evaluate preventive measures should be designed with an eye to generating information pertinent to the inevitable reimbursement questions. 169

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REFERENCES Personal communication. Dr. T. Franklin Williams, Director, National Institute on Aging, NIH, Bethesda, Maryland. 2. Selden, D. Presidential Address to the Association of American Physicians, 1981. As quoted by Dr. Paul B. Beeson in "Towards Reaching Health Policy for the Elderly. Conclusions and New Policy Directions," presented at the Annual Meeting of the Institute of Medicine, October 20, 1982. '. Flexner, A. Medical Education in the United States and Canada . A Report to the Carnegie Foundation for the Advancement of Teaching. Bulletin Number 4 (1910~. Washington, D.C.: Science and Health Publications, 1960. 4. Institute of Medicine. Aging and Medical Educat ion. Washington, D. C.: National Academy Press, 1978. 5. Somers, A. R. and Fabian, O. R., eds. The Geriatric Imperative: An Introduction to Gerontology and Clinical Geriatrics. New York: Appleton-Century-Crof ts, 1981. 6. Association of American Medical Colleges. Proceedings of the Regional Institutes on Geriatrics and Medical Education. Washington, D. C .: AAMC, 1983. 7 . Department of Health, Education, and Welfare; Heal th Resources Administration. Health United States 1976-1977. DHEW - Publication No . (HRA) 77-1232. Washington, I). C.: U. S. Government Printing Office, 1977. 8. Department of Health and Human Services; Public Health Service. Health United States, 1982. DHHS Publication No . (PHS ~ 83-1232 . Washington, D.C.: U. S. Government Printing Office, 1982. 9. Estes, E. H. Health experience in the elderly. In Busse, E. W. and Pfeiffer, E., eds., Behavior and Adaptation in Late Life. 2nd ed. Boston: Little ~ 10. AAMC Steering Committee Report, Undergraduate medical education preparation for improved geriatric care--A guideline for curriculum assessment. In Reference #6. 11. Freeman, J. R. A survey of geriatrics education: catalogues of United States medical schools. Journal of the American Geriatrics Society 19:746-762, 1971. 12. Association of American Medical Colleges. 1981-82 AAMC Curriculum Directory. Washington, D.C.: AAMC, 1981. 13. Robbins, A. S. and Beck, J. C. Guidelines for graduate medical education in geriatrics. Journal of Medical Education 57:762-768, 1982. 170

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14. Spence, D., et al. Medical student attitudes toward the geriatric patient. Journal of the American Geriatrics Society 16:976-983, 1968. 15. Gale, J., and Livesley, B. Attitudes towards geriatrics: A report of the King ' s survey. Age and Ageing 3: 49-53, 1974 . 16 . Kutner, N. G. Medical students' orientation toward the chronically ill. Journal of Medical Education 53:111-117, 1978. 17. Coker, R. E., et al. Patterns of influence: Medical school faculty members and the values and specialty interests of medical students. Journal of Medical Education 35:518-527, 1960. 18. Butler, R. N. The future of geriatric medicine. In Reference #6. 19. Beeson, P. B. Inhibitions to integrating geriatrics in medical education. In In Reference #6. 20. Institute of Medicine. Hamburg, D. A ., Elliott, G. R., and Parron, D. L., eds. Health and Behavior: Frontiers of Research in the Biobehavioral Sciences. Washington, D.C.: National Academy Press, 1982. 21. Centers for Disease Control. Ten Leading Causes of Death in the United States, 1977. Washington, D.C.: U.S. Goverament Printing Office, 1980. ~2. Elliott, G. R., and Eisdorfer, C., eds. Stress and {lumen Health. New York: Springer,.1982. 23. Goldberg, D. Training family physicians in mental health skills: Implications of recent research findings. In Mental Health Services in Primary Care Set sings : Report of a Conference, April 2-3, 1979. (Parron, D. L. and Solomon, F., eds. ~ DHHS Publ. No. (ADM) 80-995 . Washington, D. C.: U. S. Government Printing Of f ice, 1980. 24. Blackwell, B. and Torem, M. Behavioral science teaching in U. S. medical schools: A 1980 national survey. American Journal of Psychiatry 139:1304-1307, 1982. National Board of Medical Examiners. Bulletin of Information and Description of Examinations. Philadelphia: NBME, January 1976. 26. Parron, D. L. and Solomon, F. teds.) Mental Health Services in Primary Care Settings: Report of a Conference, April 2-3, 1979. DHES Publication No. (ADM) 80-995. Washington, D.C.: U.S. Government Printing Office, 1980. 27. Eisenberg, L., and Kleinman, J., eds. The Relevance of Social Science for Medicine. Boston: D. Reidel, 1981. 171

OCR for page 148
28. Pardes, [I. Medical education and recruitment in psychiatry. American Journal of Psychiatry 139:1033-1035, 1982. 29. Yager, J., Lamotte, K., Nielsen, A., and Eaton, J. S. Medical students' evaluation of psychiatry: A cross-country comparison. American Journal of Psychiatry 139:1003-1009, 1982. 30. Weintraub, W., Balls, G. U., and Donner, L. Tracking: An answer to psychiatry's recruitment problems ? American Journal of Psychiatry 139 :1036-1039, 1982. 31. Sierles, F. Medical school factors and career choice of psychiatry. American Journal of Psychiatry 139 :1040-1042, 1982. 32. DeFriese, G. H., et al. Health Promotion/Disease Prevention in the Clinical Practice of Medicine and Dentistry. Chapel Hill, N.C.: The Health Services Research Center, University of North Carolina, 1981. 33. Institute of Medicine. Healthy People: The Surgeon General's Report on Health Promotion and Disease Prevention. Background Pa pers . DREW (PHS) Publ. No. 79-55071A. Washington, D.C.: U. S. Government Printing Off ice, 1979. 34. Nightingale, E. O., Cureton, M., Kalmar, V., and Trudeau, M. B. Perspectives on Health Promotion and Disease Prevention in the . ,, United States. A staff paper of the Institute of Medicine. Washington, D. C.: National Academy of Sciences , 1978. Office of Health Research, Statistics, and Technology. Health United States: 1980 (with Prevention Prof lie ~ . DHHS Publ. No. (PHS) 81-1232. Washington, D.C.: U. S. Government Printing Office, 1980.. 36. Lewis, C. E. Teaching medical students about disease prevention and health promotion. In Prevention and Medical Practice: The Role of Undergraduate Medical Education. Report of a National - Symposium. Public Health Reports 97:210-215, 1982. 37. Technical Committee on Health Services. John Beck, Chairman. Report to the 1981 White House Conference on Aging. Washington, D. C.: U. S . Government Printing Of f ice , 1981. 38. Somers, A. R. and Weisfeld, V. Need for prevention and lifetime health maintenance. In Somers, A. R., et al. Long-Term Care for the Elderly: Crisis and Challenge. Rock~ille, Md.: Aspen - Systems (titles tentative; scheduled for publication in 1983). 39. McNamara, D. G. Preventive health services: The physician ' s role. In Prevention and Medical Practice: The Role of Undergraduate Medical Education. Report of a National Symposium. Public Health Reports 97:224-226, 1982. 172

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40. Segall, A., et al. A general model for preventive intervention in clinical practice." Journal of Medical Education 56:324-333, 1981. 41. Jonas, S. A perspective on educating physicians for prevention. In Prevention and Medical Practice: The Role of Undergraduate . Medical Educat ion. Report of a National Symposium. Public Health Reports 97 :199-204, 1982. 42. Torrens, P. R., Breslow, L., and Fielding, J. E. The role of universities in personal health improvement. Preventive Medicine 11: 477-484, 1982. 43. Bishop, F. M. Prevention in medical education: Preclinical content. In Prevention and Medical Practice: The Role of . Undergraduate Medical Education. Report of a National Symposium. Public Health Reports 97: 232-234, 1982. 44. Andrus, P. L. Prevention in medical education: Clinical content. In Prevention and Medical Practice: The Role of Undergraduate Medical Education. Report of a National - Symposium. Public Health ~ports 97: 235-238, 1982 . 45. Sackett, D. L. Learning clinical epidemiology and biostatistics in a formally integrated medical curriculum. In Clark, D. W. (ed.), Academic Relationships and Teaching Resources, Sixth in a series on Teaching of Preventive Medicine. DREW Publ. No. (NIH) 76-880. Washington, D.C.: U. S. Government Printing Office, 1976. 46. Arnold, C. B. The road ahead. In The Place of Prevention in Medical Education: _Past, Present, and Future. Report of a Forum. Preventive Medicine 10: 736-740, 1981. 47. Collins, T. R. Curriculum content and educational processes in preventive medicine graduate education. In Byrd, B. A., ea., Charting Graduate Education in Preventive Medicine. Report of the 1980 National Conference. Washington, D.C.: American College of Preventive Medicine, no date. 48. Byrd, B. A., Keimowitz, H. K., and Peterson, K. W., eds. Directory of Preventive Medicine Residency Programs in the United States and Canada, 2nd ed. Washington, D.C.: American College of Preventive Medicine, 1981 e 49. Nenhauser, D. Don't teach preventive medicine: A contrary view. Public Health Reports 97: 220-222, 1982. 50. Jonas, S. Health-oriented physician education. Preventive Medicine 10: 700-709, 1981 . 51. Kane, R., Woolley, F. R., and Kane, R. Toward defining the end product of medical education. Journal of Medical Education 48:615-624, 1973. 173

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52. Robinowitz, C. B. Prevention in medical education: Research and faculty development. In Prevention and Medical Practice: The Role of Undergraduate Medical Education. Report of a National Symposium. Public Health Reports 97: 235-238, 1982. 53. Berg, R. L. Prevention: Current status in undergraduate medical education. In Prevention and Medical Practice: The Role of Undergraduate Medical Education. Report of a National Public Health Reports 97 :205-209, 1982. Symposium. 54. McBean, A. M. and Yodaiken, R. E. Financing specialty training in preventive medicine. In Byrd, B. A., ea., Charting Graduate Education in Preventive Medicine. Report of the 1980 National American College of Preventive Conference. Washington, D. C.: Medicine, no date. 55. National Institutes of Health (John E. Fogarty International Center for Advanced Study in the Health Sciences ~ and the American College of Preventive Medicine. Education and Training of Health Manpower for Prevention. Report of a Task Force chaired by John H. Bryant. Series Title: Preventive Medicine USA. New York: Prodist, 1976. 174