A mapping process for identifying and enhancing public health education in required medical student clerkships.

This is one of six short papers that describe additional innovations to help integrate public health into medical education; these were featured in the "Patients and Populations: Public Health in Medical Education" conference. They represent relatively new endeavors or curricular components that had not been explored in prior publications. Although evaluation data are lacking, it was felt that sharing a description of the mapping process for linking public health competencies to clinical clerkship activities at the University of Wisconsin School of Medicine and Public Health would be of value to medical educators.

Urinary tract infections.

Urinary tract infection (UTI) is the most common urologic disorder and one of the most common conditions for which physicians are consulted. Patients at increased risk for UTI include women; diabetics; the immunocompromised; and those with anatomic abnormalities, impaired mobility, incontinence, advanced age, and instrumentation. Antibiotic therapy aims to relieve symptoms and prevent complications such as pyelonephritis and renal scarring. Distinguishing asymptomatic bacteriuria from a UTI can be difficult, especially in those with comorbidities. Most experts do not recommend screening for UTI, except in the first trimester of pregnancy.

Sexually transmitted infections in men.

Sexually transmitted infections (STIs) cause tremendous morbidity, great costs, and numerous avoidable deaths in the United States each year. STIs in men can present as discharge, ulcers, papules, infestations, or systemic disease, but most commonly STIs present without any symptoms. Molecular techniques, single-dose antibiotics and antivirals, and patient-administered therapies present opportunities for enhanced diagnosis and treatment. Screening for STIs should be part of all primary care practices, specifically targeting high-risk persons and those diagnosed with another STI.

Diagnosis and treatment of urethritis in men.

Symptoms of urethritis in men typically include urethral discharge, penile itching or tingling, and dysuria. A diagnosis can be made if at least one of the following is present: discharge, a positive result on a leukocyte esterase test in first-void urine, or at least 10 white blood cells per high-power field in urine sediment. The primary pathogens associated with urethritis are Chlamydia trachomatis and Neisseria gonorrhoeae. Racial disparities in the prevalence of sexually transmitted infections persist in the United States, with rates of gonorrhea 40 times higher in black adolescent males than in white adolescent males. Recent studies have focused on identifying causes of nongonococcal urethritis and developing testing for atypical organisms, such as Mycoplasma genitalium and Ureaplasma species. Less common pathogens identified in patients with urethritis include Trichomonas species, adenovirus, and herpes simplex virus. History and examination findings can help distinguish urethritis from other urogenital syndromes, such as epididymitis, orchitis, and prostatitis. The goals of treatment include alleviating symptoms; preventing complications in the patient and his sexual partners; reducing the transmission of coinfections (particularly human immunodeficiency virus); identifying and treating the patient's contacts; and encouraging behavioral changes that will reduce the risk of recurrence. The combination of azithromycin or doxycycline plus ceftriaxone or cefixime is considered first-line empiric therapy in patients with urethritis. Expedited partner treatment, which involves giving patients prescriptions for partners who have not been examined by the physician, is advocated by the Centers for Disease Control and Prevention and has been approved in many states. There is an association between urethritis and an increased human immunodeficiency virus concentration in semen.

Neonatal circumcision model and competency evaluation for family medicine residents.

Neonatal circumcision is one of the most common procedures performed by family physicians and is a recommended procedure for resident training. Few models or simulators exist. A model of neonatal genitalia was constructed using a cocktail wiener covered by a surgical glove finger. A competency checklist was used to review the steps of the procedure. Posttest/pretest-posttest assessment found significant improvement in knowledge and comfort in three groups of learners. Ninety percent of participants were deemed competent in all 15 areas of the checklist. The easily replicable model was felt to reasonably model the neonatal genitalia for circumcision training.

Community medicine in action: an integrated, fourth-year urban continuity preceptorship.

OBJECTIVE: To provide an opportunity for fourth-year students at the University of Wisconsin Medical School in Madison to immerse in urban community medicine during a 34-week program. This experience enhances the integrity of the fourth year as well as merges medicine and public health perspectives in medical education as called for by the Medicine and Public Health Initiative. DESCRIPTION: A limited number of fourth-year Wisconsin medical students have the opportunity to select a one-year, continuity-based preceptorship at the Milwaukee clinical campus with a focus in one of three domains: family medicine, internal medicine, or women's health. Students participate in the following clinical activities: a one-year, integrated preceptorship (one to three half days per week in a primary preceptor's office), medicine subinternship, senior surgery clerkship, selectives (16-20 weeks of clerkships relevant to preceptorship focus area), and one month of out-of-city electives. Complementing this community-based clinical experience is the opportunity to develop an increased appreciation for urban community health issues and resources by participating in a required urban community medicine clerkship and a mentored student scholarly project focusing on an aspect of urban community medicine and population health. All students begin the year in July with a four-week urban community medicine clerkship, which is based on the St. Luke's family practice residency's community medicine rotation and arranged by residency faculty. They conduct a "windshield survey" of a Milwaukee neighborhood, observing health hazards and identifying assets, and then present these observations to others in the clerkship. During this first month, students are introduced to the work of a variety of social service agencies, the Milwaukee City Health Department, and the Aurora Health Care/UW community clinics, which serve the state's most diverse zip codes. They meet with providers and researchers who share their expertise in infectious disease, preventive medicine, perinatal epidemiology, domestic violence, sexual assault, and disease management. Students develop increased understanding of barriers to health and personal resilience by listening to focus groups conducted with homeless men and undocumented Latino women. They participate in a resident and faculty development retreat on enhancing community medicine knowledge and skills. By August, students select an advisor and outline a project designed to expand understanding in the areas of urban population health research, community health education, professional education, or health intervention planning and evaluation. Faculty members at the Center for Urban Population Health work closely with the students throughout the year, which includes two weeks in the spring that are dedicated to intensive work on the projects. DISCUSSION: This fourth-year, urban community-based preceptorship is designed to provide students with an alternative fourth year that integrates skill development in clinical and community medicine, offers a continuity primary care experience, and showcases innovative urban health resources and role models. It is hoped that these students will pursue graduate medical education in Milwaukee, incorporate a population perspective in their practice, and choose to work in neighborhoods that are currently underserved.

Training community-responsive physicians.

OBJECTIVE: The "community-responsive" primary care provider has a population health perspective and is prevention-oriented, culturally competent, collaborative, and an active community leader and patient advocate. To encourage residents to value this level of community involvement and possess the requisite knowledge and skills, St. Luke's family practice residency program has developed a longitudinal community medicine curriculum designed to teach the four domains of physician-community involvement: (1) insight into sociocultural aspects of patient care, (2) familiarity with community health resources, (3) community-oriented primary care skills, and (4) community involvement.(1) Training physicians with the desire and skills to practice in medically underserved communities is a program goal. DESCRIPTION: The three-year community medicine curriculum begins during residency orientation with a windshield survey of the communities served by the campus-related clinics. During the first year, all residents participate in a four-week community medicine rotation. By providing health education and clinical services to diverse populations in community clinics, agencies, and schools, they begin to develop community health-improvement skills, while observing role models, developing advocacy skills, expanding cultural awareness, and experiencing interdisciplinary collaboration. At the end of the first year, residents select a community clinical site, where they will see patients and develop a community health-improvement project during the last two years of training. A required "capstone presentation" describes the scope and nature of each resident's project by focusing on process and outcome measures. Innovative qualitative evaluation tools include a written portfolio of reflections and sequential "video journaling." An attribute-based progression matrix developed by Alverno College was adapted to facilitate serial identification and tracking of resident growth in eight domains: communication, analysis, problem solving, aesthetic responsiveness, global perspectives, valuing in decision making, social interaction, and effective citizenship.(2) Support for this program is provided by HRSA, Wisconsin AHEC, Aurora Health Care, and the medical school. DISCUSSION: A recent program graduate, now a faculty member, demonstrated the potential for this educational strategy by developing a local "Reach Out and Read" program. Targeting literacy as a factor related to the cycle of poverty and poor health, she implemented an intervention in which residents read with their pediatric patients during each visit and give the child a book to take home. As each residency class implements health-promoting interventions, this longitudinal community medicine residency curriculum will improve community health through "service learning," as well as develop a cadre of young physicians who practice community-responsive clinical medicine and have the skills and confidence to choose to serve underserved populations.