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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?
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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.
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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
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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
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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.
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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.
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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.
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174
Representative terms from entire chapter:
preventive medicine
