A collaborative clerkship with a focus on rural community health.

The Deans' Rural Primary Care Clerkship was developed through the collaborative efforts of South Carolina's two medical schools. The clerkship provides students an innovative learning experience in rural community medicine through the unique combination of learning opportunities with community-oriented primary care, continuous quality improvement, interdisciplinary health care teams, and cultural competency. Much of students' learning addresses current directives for population health training. The positive experience students are having in these rural, underserved South Carolina communities will help them better understand the rewards and challenges of rural, community-responsive health care.

Prevention education and evaluation in U.S. medical schools: a status report.

The Prevention Curriculum Assistance Program (PCAP) was initiated to help U.S. medical schools examine the extent to which they are evaluating the learning of medical students about disease prevention/health promotion. A survey was sent to all 144 allopathic and osteopathic medical schools, with an overall response rate of 68%. The results revealed more emphasis on teaching and evaluating the learning of medical students in the areas of clinical preventive services and quantitative methods, and less emphasis on the community dimensions of medical practice and health services organization and delivery. Written tests and unstructured observation are the most common methods of evaluation. Fewer than half of all respondents were satisfied with the quality of their assessment of student achievement in any of the four domains of prevention education. More than 30% expressed a desire to receive assistance with designing curricula and/ or evaluation methods in each of the four content areas examined. Several indicated their willingness to assist colleagues who want to improve their prevention curricula and/or measurement strategies. This study identified a need for more attention and support for prevention education and evaluation programs. Curriculum leaders can help by designating prevention a priority area and appointing faculty to be responsible for monitoring the content and quality of prevention teaching throughout the curriculum. Resources such as the Internet can be utilized to establish a network whereby medical schools can collaborate to improve their educational programs and evaluation methods in prevention.

Evaluation methods for prevention education.

The knowledge, skills, and attitudes associated with prevention cut across clinical disciplines. Thus, they are often subsets of disciplines not otherwise present in the traditional curriculum (e.g., epidemiology or statistics) or considered the province of many disciplines (e.g., risk reduction or cancer screening). Evaluation of elements of prevention education can often become lost in the myriad other outcomes that are assessed in students, or they are intermingled with other content and skills. This article highlights the value of assessing students' competence in prevention knowledge, skills, and attitudes, provides general guidance for programs interested in evaluating their prevention instructional efforts, and gives specific examples of possible methods for evaluating prevention education. While it is important to tailor assessment methods to local institutional objectives, it is possible to share assessment methods and materials regionally and nationally. Sharing problems, as well as successes, encountered in developing appropriate assessment methods will advance the field of evaluation of prevention curricula.

Curricular renewal for the new millennium at the Medical University of South Carolina College of Medicine.

The MUSC College of Medicine is engaged in a curricular renewal process that emphasizes increased integration of the basic and clinical sciences throughout all four years of the curriculum, more self-directed learning, and earlier patient contact for students. Several basic science courses have been modified and a new "Doctoring Curriculum" has been introduced to develop students' clinical skills and preparation for medical practice. Changes to the third year of the curriculum include the new Deans' Rural Primary Care Clerkship. Other third-year curricular changes include small-group case discussion sessions that emphasize the integration of basic and clinical sciences in medical practice, and the incorporation of nutrition throughout all fours of the curriculum. The changes described in this manuscript are designed to address a wide range of educational needs of future physicians, including the acquisition of the attributes endorsed by the AAMC MSOP--altruism, knowledge, skillfulness and dutifulness. This new curriculum will evolve over time and the goal remains to help equip future physicians with the requisite knowledge, skills and attitudes for medical practice in the new millennium.

An office system for organizing preventive services: a report by the American Cancer Society Advisory Group on Preventive Health Care Reminder Systems.

Despite increasing recognition of the importance of preventive services, such services are not provided in primary care practice as often as recommended. One of the most important reasons is the lack of a systematic, organized approach within practices. The American Cancer Society Ad Hoc Advisory Group on Preventive Health Care Reminder Systems reviewed evidence-based reports and expert opinion to summarize current knowledge about office systems for clinical preventive services. This article describes the process of developing an office system for preventive care, beginning with writing a practice policy, auditing charts for baseline performance, developing and implementing a plan for efficient delivery of preventive care, involving office staff, and monitoring progress. Strategies for dissemination of this approach to a wide range of primary care practices may involve professional medical organizations and managed care companies.

Implementation and evaluation of a computer-based preventive services system.

BACKGROUND AND OBJECTIVES: Insufficient attention has been paid to the role that modern information systems can play in improving the delivery of and education about preventive services in family medicine training and practice sites. From September 1990-September 1993, the Department of Family Medicine at the Medical University of South Carolina conducted a demonstration project designed to develop, implement, and evaluate a comprehensive, computer-based preventive services delivery and educational system, based on the recommendations in the US Preventive Services Task Force (USPSTF) Report. METHODS: A computer-based patient record (CPR) system was implemented. The system had sophisticated preventive services tracking and reminder, physician, and patient education features. Twenty-nine basic USPSTF recommendations were incorporated in the system. An extensive physician education series was also implemented. A multi-method evaluation system, including patient exit surveys, physician interviews, and practice audits was used to evaluate and design improvements to the CPR and education systems. RESULTS: Although the system initially had no effect on patient perceptions about the frequency of preventive services delivery, there was reasonable concordance between patient desires and physician behavior for the discussion of preventive services (Kappa = .5 to .6). Physician acceptance of the system was good--in 1992, 30% of physicians used the preventive services reminders in most of their patient visits, and in 1993, 88% of physicians reported more frequent use. Practice audits from February 1992-July 1993 showed increased adherence with all seven counseling services, 10 of 15 screening services, and one of five immunization services. CONCLUSIONS: A CPR-based preventive services system coupled with an adaptable physician education about and delivery of preventive services. an ideal solution to improving the education about and delivery of preventive services.

National survey on hospital-based privileges in family practice obstetrics.

PURPOSES: To document the content and level of obstetrical hospital-based privileges for members of the American Academy of Family Physicians and to describe variations between regions, rural vs urban practices, and various physician characteristics. METHODS: About 12% of the active members of the American Academy of Family Physicians listed as offering obstetrical care by the Academy as of March 1991 were randomly sampled by mailed questionnaire. Samples were drawn from three national regions. Privileges were grouped by degree of restriction, based on whether consultation or transfer was required. RESULTS: Of 1464 surveys mailed, 1026 physicians (70%) responded. Only 740 (72%) stated that they still practiced obstetrics. Privileges ranged from least restricted (100% provided vaginal vertex delivery, with no consultation required) to most restricted (79% provided amniocentesis, with consultation or transfer required). A surprisingly large proportion of physicians reported having fewer routine and more advanced privileges without consultations being required, such as ultrasonography (53%), vaginal breech delivery (41%), and cesarean section (25%). Physicians having more advanced privileges tended to be located in the West or mountain-plains region; be trained in the Midwest, mountain-plains region, or the West; work in middle-sized, nonteaching hospitals in more rural countries; have completed advanced obstetrical training (> or = 6 months); and deliver more than 40 infants per year. CONCLUSIONS: Overall, a considerable number of hospital-based obstetrical privileges are granted to family physicians. No uniformity in privileges prevails, owing to significant regional and practice variations. Teaching hospitals reportedly restrict obstetrical care by family physicians more than other hospitals. The variations in restrictions could not be explained by degree of training.

Improving a preventive services reminder system using feedback from focus groups.

OBJECTIVE: To improve the computer-generated preventive services patient reminder letter used by a department of family medicine at a medical university in South Carolina. DESIGN: A qualitative method chosen because of its demonstrated efficacy in generating in-depth attitude and opinion data was used for 12 focus groups (111 participants) in which participants were asked to evaluate the reminder letter and other preventive services reminder materials. Information from these groups was used to design a revised patient reminder system that was tested in six additional focus groups (50 participants). SETTING: University-based family medicine center. PARTICIPANTS: Adults 19 years of age or older of whom approximately one half were selected from a random sample of family medicine center patients and the remainder from volunteers recruited from the general community by newspaper advertisement. INTERVENTIONS: None. MAIN OUTCOME MEASURES: Participants' perceptions and attitudes about the reminder letter and other materials as well as suggestions for improving the preventive services reminder system. RESULTS: The revised patient reminder materials resulted in a warmer, more personal letter sent to patients at the time of their birthdays in an envelope containing a prevention message. A leaflet describing the rationale for preventive services and answering common questions about prevention and a booklet describing the preventive services available at the family medicine center were also developed. CONCLUSION: This study illustrated the benefits of incorporating patients' perspectives in the design of preventive services reminders.

Characteristics and job satisfaction of nonphysician full-time family medicine faculty members.

BACKGROUND: Nonphysician educators comprise a significant portion of the faculty in family medicine, yet little is actually known about this cohort of educators. This survey identifies and examines the population of nonphysician faculty. METHODS: a questionnaire was sent to 859 nonphysician faculty teaching full time in 113 family medicine departments and 377 family medicine residency programs. The questionnaire was used to determine the composition, characteristics, and levels of job satisfaction of respondents. The responses of this nonphysician cohort were compared to responses of physician faculty who participated in a previous study. RESULTS: Nonphysician faculty were more satisfied with the jobs they performed than they were with the recognition and rewards they received. Satisfaction levels of nonphysicians were significantly greater than their physician colleagues in the areas of research, clinical work, and administration. Physicians were significantly more satisfied than nonphysicians only in response to questions relating to teaching. CONCLUSIONS: Further research is needed to determine how to optimally integrate nonphysicians into family medicine education and fully utilize their expertise.

Incorporating a community-oriented approach in primary care.

The health care system in the United States depends on primary care services. Yet the limitations imposed by traditional approaches in primary care have resulted in an unrealized potential for primary care. Currently, we rely on the motivation and initiative of persons to acquire the health care services they need, and health care providers have attempted to meet these needs. Community-oriented primary care provides an opportunity for primary care physicians to expand their range of services and their ability to reach out to people. Incorporating community-oriented primary care into primary health care has the potential to make a major contribution in reshaping health care in the United States.

Barriers to adherence to preventive services reminder letters: the patient's perspective.

BACKGROUND: Despite an emerging consensus as to which preventive services are appropriate, a minority of patients receive them. Although adherence to recommendations for some interventions has increased, research studies have shown that adherence rates can be further improved through a better understanding of patient attitudes and motivations regarding preventive services. METHODS: Using components of the Patient Path Model, this study examined the response to patient reminder letters for cholesterol screening sent to 1077 adult patients between August and October 1990. The research strategy incorporated both quantitative and qualitative methods, including a telephone survey and focus group interviews of nonresponders to the reminder letter. RESULTS: Three hundred seven patients were surveyed by telephone to ascertain their reasons for nonresponse. One hundred fifty-four (50.2%) did not recall receiving the reminder letter, 84 (27.4%) recalled receiving the letter but did not recall its content, and 69 (22.5%) recalled both receiving the letter and its content. No consistent reason for nonadherence emerged among the 69 nonresponders who recalled the reminder. Twenty-seven of the nonresponders who did not recall receiving the cholesterol reminder participated in the focus groups. The participants stressed the importance of distinguishing the reminder letter from a bill, conveying a personally relevant message, and addressing logistical barriers to preventive services. CONCLUSIONS: Careful attention to the format and content of patient reminder letters is necessary to improve adherence to preventive services recommendations.

A comprehensive microcomputer-based medical records system with sophisticated preventive services features for the family physician.

BACKGROUND: Computer-based medical records systems improve the provision of preventive services in the offices of family physicians. Until recently, these systems were either not commercially available for use by practicing physicians or were very expensive. METHODS: A commercially available, microcomputer-based medical records system is currently used at the Department of Family Medicine at the Medical University of South Carolina. This system is used as a fully electronic medical record and has sophisticated health maintenance tracking and reminder features. These features track the provision of preventive services, provide physician reminders at the time of patient visits, permit generation of mailed patient reminders, and provide reference to relevant patient education resources. RESULTS AND CONCLUSION: The system described in this paper can be used by practicing physicians to improve their delivery of preventive services.

The effect of routine use of computer-generated preventive reminders in a clinical practice.

Computer-generated reminders for patients and physicians can increase provision of preventive services. On July 1, 1989, the Department of Family Medicine at the Medical University of South Carolina extended a computerized prevention reminder system to all physicians and adult patients in the department's clinical practice. The prevention program consisted of computer-generated physician reminders for any deficiencies in five preventive services at the time of patient visits, a personalized patient reminder letter sent just before a patient's birthday, and educational interventions. We defined adherence using a population-based approach, that is, the percentage of all eligible patients who had received the preventive services within the recommended period of time. The data revealed that the percentage of patients who received preventive services either increased or remained stable during the 12-month study period, which ended July 1, 1990. Adherence was greater for women, for older patients, and for those with Medicare/Medicaid and HMO insurance. We noted higher rates of adherence for all five preventive services, compared with baseline rates of adherence recorded on July 1, 1988. A population-based approach to prevention allows physicians to become more active in providing preventive care to patients. Computer-based reminder and tracking systems can integrate population-based prevention into practice.