Innovative generalist programs: academic health care centers respond to the shortage of generalist physicians.

Academic health care centers increasingly are exploring innovative ways to increase the supply of generalist physicians. The authors review successful innovations at representative academic health centers in the areas of recruitment and admissions, undergraduate medical education, residency training, and practice support. Lessons learned focus on those areas that have demonstrated improvements in the number and quality of physicians trained in family practice, general pediatrics, and general internal medicine. Successful recruitment of generalism-oriented applicants requires identification and tracking of rural, minority, and other special groups of students at the high school and college levels. Academic health care centers that provide early, sustained, community-based, ambulatory experiences for medical students and residents encourage trainees to maintain and choose generalist careers. Finally, academic health care centers that link with community providers and with state government encourage the retention of generalist physicians through continuing education and teaching networks.

The New Mexico experiment: educational innovation and institutional change.

Over the past ten years the University of New Mexico School of Medicine has conducted an educational experiment featuring learner-centered, problem-based, community-oriented learning. The experiment was introduced into an established institution by means of an innovative educational track running parallel to the more conventional curriculum. Students in the innovative track, compared with those in the conventional tract, tended to score lower on the National Board of Medical Examiners (NBME) Part I examination (basic sciences) and higher on NBME Part II (clinical sciences), received higher clinical grades on clinical clerkships, and experienced less distress. They were more likely than conventional-track students to retain their initial interest in or switch their preference to careers in family medicine. The parallel-track strategy for introducing curriculum reform succeeded in fostering institutional acceptance of continuing educational innovation. Generic steps in overcoming institutional barriers to change are identified.

Osseous destruction by neurofibroma diagnosed in infancy as "desmoplastic fibroma".

A 2-month-old male infant presented with a lytic lesion of the distal radius which was diagnosed as desmoplastic fibroma. Tumor recurred following en bloc resection of the distal radius and forearm, necessitating an elbow disarticulation. Subsequently, the child developed multiple café-au-lait spots, and histologic sections have been reinterpreted as neurofibromatosis. This case illustrates the potential difficulty in diagnosing neurofibromatosis when few or no classic stigmata of the disease are present.

Undergraduate medical education for primary care: a case study in New Mexico.

To address the dual problems of maldistribution of physicians and an increasing need for physicians who are lifelong learners, an experimental curricular track was developed at the University of New Mexico School of Medicine. Increased student responsibility for learning is encouraged by student-centered, small-group, problem-based tutorial learning, and early, primary care role modeling is offered during an early, lengthy, rural preceptorship. Preliminary outcomes reveal there is reinforcement of career interest in rural primary care with important linkages forged between the university and communities as a program by-product. Further, the experimental students, as compared to students in the conventional track, showed a greater appreciation of their learning environment, showed less stress, and failed to become cynical. The reorientation of undergraduate medical education toward the future health care needs of communities and the learning needs of physicians may require major modifications of curriculum design and role modeling experiences.

Teaching clinical skills to pre-clinical medical students: integration with basic science learning.

Clinical skills are usually learned by pre-clinical students in a manner divorced from their basic science foundations. The value of previously learned basic sciences thus fails to be re-enforced. A clinical skills course was developed for an experimental curriculum of medical students in their first year. It was organized and taught by a team of basic and clinical scientists and emphasized the basic pathophysiological principles underlying clinical skills. Sessions were supported by related basic science audiovisual resources and a series of clinical problems with questions obliging the student to reason through basic-science mechanisms. Over the span of the course, students' interest shifted dramatically from a focus on proficiency in motor skills to an understanding of basic pathophysiological mechanisms underlying observed phenomena. Compared to conventional curriculum students, those in the experimental curriculum failed to show a diminution in perceived value of basic sciences in their future career and, on cumulative, cognitive examinations, scored equally in basic science, but significantly higher in clinical science subjects. A clinical skills course integrating both teachers and concepts from basic, as well as clinical sciences can improve student attitudes toward basic sciences.