Training in Urban Medicine and Public Health: Preparing Physicians to Address Urban Health Care Needs.

BACKGROUND: Wisconsin is facing significant physician shortages. The University of Wisconsin School of Medicine and Public Health (UWSMPH) launched Training in Urban Medicine and Public Health (TRIUMPH) to recruit and prepare medical students to serve people living within urban Health Professional Shortage Areas. METHODS: Students are selected based on their commitment to improve health equity for urban populations. They complete clinical rotations, core curriculum, and community projects in Milwaukee, Wisconsin. RESULTS: Full program graduates are more likely to match into residencies serving the urban poor (50/50, 100%) and pursue primary care specialties (40/50, 80.0%) compared to nonprogram graduates. DISCUSSION: The TRIUMPH program has been successful in its mission to encourage graduates to serve urban communities. The authors discuss urban health disparities, TRIUMPH outcomes, and the need for similar programs.

Understanding the needs and concerns of senior faculty in academic medicine: building strategies to maintain this critical resource.

PURPOSE: The average age of medical school faculty is increasing, with 30% over age 55 in 2007. In 2012, 56% of Society of Teachers of Family Medicine (STFM) members were at least 50 years old. The authors sought to identify the transition and faculty development needs of this group of senior faculty. METHOD: In 2012 the authors electronically surveyed 1,708 U.S. STFM members who were 50 or older, asking about demographics, highest degree, primary employer, career options considered in the previous year, issues of concern, mentoring needs, retirement plans, and likely activities in retirement. RESULTS: The response rate was 45%, with 73% MD/DOs, 62% men, 89% white, and 64% employed by academic institutions. The most frequent issues of concern were balancing personal and work time (67%), maintaining health (66%), and planning for retirement (60%). Nearly a third had considered career advancement, changing employers, or reducing full-time employment. Fifty-one percent were not receiving mentoring of any kind, but 47% reported they would like to have a mentor. Sixty-four percent were planning to retire; in retirement, 75% said they would like to remain active in teaching and 55% in mentoring. CONCLUSIONS: Senior faculty in family medicine have significant career concerns and mentoring needs as they approach retirement, and these faculty can be valuable resources after retirement. As the age of faculty continues to rise, medical schools and specialty organizations can develop specific programs to meet the needs of these medical educators and better use this expertise in a time of limited resources.

Training in Urban Medicine and Public Health: TRIUMPH.

PURPOSE: The number of U.S. medical school graduates who choose to practice in health professional shortage areas (HPSAs) has not kept pace with the needs of society. The University of Wisconsin School of Medicine and Public Health has created a new program that prepares medical students to reduce health disparities for urban medically underserved populations in Milwaukee. The authors describe the Training in Urban Medicine and Public Health (TRIUMPH) program and provide early, short-term outcomes. METHOD: TRIUMPH integrates urban clinical training, community and public health curricula, longitudinal community and public health projects, mentoring, and peer support for select third- and fourth-year medical students. The authors tracked and held focus groups with program participants to assess their knowledge, skills, satisfaction, confidence, and residency matches. The authors surveyed community partners to assess their satisfaction with students and the program. RESULTS: From 2009 to 2012, 53 students enrolled in the program, and 45 have conducted projects with community organizations. Participants increased their knowledge, skills, confidence, and commitment to work with urban medically underserved populations. Compared with local peers, TRIUMPH graduates were more likely to select primary care specialties and residency programs serving urban underserved populations. Community leaders have reported high levels of satisfaction and benefits; their interest in hosting students exceeds program capacity. CONCLUSIONS: Early, short-term outcomes confirm that TRIUMPH is achieving its desired goals: attracting and preparing medical students to work with urban underserved communities. The program serves as a model to prepare physicians to meet the needs of urban HPSAs.

Fit Kids/Fit Families: a report on a countywide effort to promote healthy behaviors.

INTRODUCTION: Funded by the Wisconsin Partnership Fund for a Healthy Future and Aurora Health Care, Fit Kids/Fit Families (FKFF) is a multidisciplinary, family system approach to weight management that was developed and implemented by a community-academic partnership with the goal of reducing and preventing childhood overweight and obesity, increasing physical activity, and improving overall family health. PROGRAM DESCRIPTION: A sample of Washington County children and their families participated in this 12-week program, which promoted healthy lifestyle changes. Data was collected pre- and post-intervention on age, height, weight, body mass index (BMI), body circumference measurements, child and family habits, and child self-esteem. A weekly nutrition, activity and behavioral log captured behaviors. Weekly 2-hour meetings in a community setting using a dietician, behaviorist, and exercise specialist addressed each of these areas. RESULTS: FKFF has served 68 children and their families. Two-thirds are female; the mean age is 10.4 years (age range, 5-16). Both parents (96%) and children (81%) demonstrated improved knowledge and attitudes regarding healthy lifestyle changes. Logs report that 59% of the children increased their physical activity and 32% reduced their sedentary activity. While 81% improved and 13% maintained BMI, 74% of the children showed decreased total body circumferences. Nearly two-thirds demonstrated improved self-esteem on the Rosenberg Self-Esteem Scale. CONCLUSION: Preliminary results suggest FKFF has an effect on healthier nutritional choices, increased physical activity, decreased sedentary activity, overall healthier behaviors, and body circumference and BMI reductions.

The family medicine curriculum resource project structural framework.

BACKGROUND: In the original contract for the Family Medicine Curricular Resource Project (FMCRP), the Health Resources and Services Administration (HRSA), Division of Medicine and Dentistry, charged the FMCRP executive committee with reviewing recent medical education reform proposals and relevant recent curricula to develop an analytical framework for the project. METHODS: The FMCRP executive and advisory committees engaged in a review and analysis of a variety of curricular reform proposals generated during the last decade of the 20th century. At the same time, in a separate and parallel process, representative individuals from all the family medicine organizations, all levels of learners, internal medicine and pediatric faculty, and the national associations of medical and osteopathic colleges (Association of American Medical Colleges and the American Association of Colleges of Osteopathic Medicine) were involved in group discussions to identify educational needs for physicians practicing in the 21st century. RESULTS: After deliberation, a theoretical framework was chosen for this undergraduate medical education resource that mirrors the Accreditation Council for Graduate Medical Education (ACGME) competencies, a conceptual design originated for graduate medical education. DISCUSSION: In addition to reflecting the current environment calling for change and greater accountability in medical education, use of the ACGME competencies as the theoretical framework for the FMCR provides a continuum of focus between the two major segments of physician education: medical school and residency.

Family Medicine Curriculum Resource Project: the future.

Under contract to the Health Resources and Services Administration (HRSA), the Society of Teachers of Family Medicine (STFM) created an undergraduate medical education curricular resource designed to train physicians to practice in the 21st century. An interdisciplinary group of more than 35 educators worked for 4 years to create the Family Medicine Curriculum Resource (FMCR). By consensus, the Accreditation Council for Graduate Medical Education (ACGME) competencies were adopted as the theoretical framework for this project. The FMCR provides materials for the preclerkship years, the third-year family medicine clerkship, the postclerkship year, and faculty development, as well as guidance for integrating topics of special interest to the federal government (such as, geriatrics, Healthy People 2010, genetics, informatics) into a 4-year continuum of medical education. There are challenges inherent in implementing each component of the FMCR. For example, can the ACGME competency-based approach be adapted to undergraduate medical education? Can the densely packed preclerkship years be adapted to include more focused effort on developing these competencies, and whose job is it anyway? What is "core" to being a competent clinician, and what information can be obtained when needed from medical informatics sources? Will family medicine educators embrace the FMCR recommendations for their third-year clerkships? Will exit assessment of the competency levels of graduating medical students be achieved, and can it make them more capable residents? Can faculty in different clinical and educational settings integrate the teaching of "how to learn" into their repertoire? How will faculty development innovation progress in a time of increasing emphasis on clinical productivity? Developing a common language and adoption of core competencies for all levels of medical education is imperative in a society that is focusing on improving health care quality and outcomes. The FMCR Project has developed a curricular resource to assist medical educators in this task. The challenge for the future is to measure how the FMCR is used and to ascertain if it has an influence on better patient and system outcomes.

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.