Teaching Competencies for Community Preceptors.

BACKGROUND AND OBJECTIVES: Although community physicians provide one-fourth of the outpatient training received in medical school, usually there is no formal training of the preceptor. Currently there is no agreed-upon list of teaching competencies for community physician-preceptors. Using a modified Delphi process, the authors aimed to identify core teaching competencies for community preceptors for use in training and evaluation. METHODS: A medical educator and three faculty members with expertise in faculty development created a list of teaching competencies organized in five domains. These competencies were finalized through a multiround modified Delphi technique with key stakeholder groups including (1) nonphysician medical educators, (2) academic physicians involved in faculty development, (3) community physicians who regularly precept medical students, (4) family medicine residents, (5) third-year medical students in a 9-month-long longitudinal clerkship. Proposed competencies were retained if 70% of the participants ranked it as "very or extremely important." RESULTS: In the first round, 24 competencies were evaluated by 40 physician preceptors participating in a rural faculty development conference. These were refined, and four additional competencies were added by the cohort. Subsequent rounds utilized a survey approach with broader audiences resulting in a final list of 21 competencies in five domains. CONCLUSIONS: Five competency domains with 21 teaching competencies can now be used to guide community preceptors' training and evaluation.

Early life adversity influences stress response association with smoking relapse.

RATIONALE: We examined the hypothesis that stress-related blunting of cortisol in smokers is particularly pronounced in those with a history of severe life adversity. OBJECTIVES: The two aims of this study were first to examine hormonal, craving, and withdrawal symptoms during ad libitum smoking and after the first 24 h of abstinence in smokers who experienced high or low levels of adversity. Second, we sought to examine the relationship between adversity and hypothalamic-pituitary-adrenal (HPA) hormones to predict relapse during the first month of a smoking cessation attempt. METHODS: Hormonal and self-report measures were collected from 103 smokers (49 women) during ad libitum smoking and after the first 24 h of abstinence. HPA hormones were measured during baseline rest and in response to acute stress in both conditions. All smokers were interested in smoking cessation, and we prospectively used stress response measures to predict relapse during the first 4 weeks of the smoking cessation attempt. RESULTS: The results showed that high adversity was associated with higher distress and smoking withdrawal symptoms. High level of early life adversity was associated with elevated HPA activity, which was found in both salivary and plasma cortisol. Enhanced adrenocorticotropic hormone (ACTH) stress response was evident in high-adversity but not in low-adversity relapsers. CONCLUSIONS: This study demonstrated that early life adversity is associated with stress-related HPA responses. The study also demonstrated that, among smokers who experienced a high level of life adversity, heightened ACTH and cortisol responses were linked with increased risk for smoking relapse.

Early Course in Obstetrics Increases Likelihood of Practice Including Obstetrics.

BACKGROUND AND OBJECTIVES: The Department of Family Medicine and Community Health Duluth has offered the Obstetrical Longitudinal Course (OBLC) as an elective for first-year medical students since 1999. The objective of the OBLC Impact Survey was to assess the effectiveness of the course over the past 15 years. METHODS: A Qualtrics survey was emailed to participants enrolled in the course from 1999-2014. Data was compiled for the respondent group as a whole as well as four cohorts based on current level of training/practice. Cross-tabulations with Fisher's exact test were applied and odds ratios calculated for factors affecting likelihood of eventual practice including obstetrics. RESULTS: Participation in the OBLC was successful in increasing exposure, awareness, and comfort in caring for obstetrical patients and feeling more prepared for the OB-GYN Clerkship. A total of 50.5% of course participants felt the OBLC influenced their choice of specialty. For participants who are currently physicians, 51% are practicing family medicine with obstetrics or OB-GYN. Of the cohort of family physicians, 65.2% made the decision whether to include obstetrics in practice during medical school. Odds ratios show the likelihood of practicing obstetrics is higher when participants have completed the OBLC and also are practicing in a rural community. CONCLUSIONS: Early exposure to obstetrics, as provided by the OBLC, appears to increase the likelihood of including obstetrics in practice, especially if eventual practice is in a rural community. This course may be a tool to help create a pipeline for future rural family physicians providing obstetrical care.

Impact of a rural interprofessional experience in rural communities on medical and pharmacy students.

BACKGROUND AND OBJECTIVES: The mission of the medicine and pharmacy programs at the University of Minnesota, Duluth campus is to prepare students for practice in rural communities. To support and encourage medical and pharmacy students to choose to practice in rural Minnesota, an interprofessional experience was developed to expose medical and pharmacy students to a variety of aspects of rural health care. The objective of this study was to determine the impact of the Rural Interprofessional Experience (RIE) on perceived knowledge and attitudes of medical and pharmacy students toward rural practice. METHODS: Medical and pharmacy students were surveyed before and after their RIE to assess student perceptions of the value of the experience. RESULTS: Analysis shows that both medical and pharmacy students demonstrated a positive change in perceived knowledge after their participation in the rural community experience. However, most attitudes toward rural community participation did not change significantly. CONCLUSIONS: The RIE of medical and pharmacy students is associated with an increase in perceived knowledge in all categories related to rural health care.

HOPE clinic: a place to care.

The University of Minnesota Medical School and College of Pharmacy in Duluth worked with a local drop-in center in 2008 to start a free clinic. The HOPE (Health of People Everywhere) Clinic is a student-run, faculty-organized effort that offers students an opportunity to develop their clinical skills and learn how to work in interprofessional teams while providing needed care to people who are underserved or uninsured. This article describes how this initiative came about and the impact it is having on medical students.

Efforts to graduate more primary care physicians and physicians who will practice in rural areas: examining outcomes from the university of Minnesota-duluth and the rural physician associate program.

PURPOSE: To compare practice choices (primary care or specialty) and practice locations (rural or metropolitan) of medical students at the Duluth and Twin Cities (Minneapolis and St. Paul; TC) campuses of the University of Minnesota (UMN). In the early 1970s, Minnesota created two medical education programs at UMN to increase the number of rural and primary care physicians: the first two years of medical school at UMN-Duluth, where the program focuses on recruiting students who will be rural family physicians, and the Rural Physician Associate Program (RPAP) elective, a nine-month, longitudinal immersion experience with a preceptor in a rural community. METHOD: In 2008, the authors analyzed outcomes for four student groups: (1) UMN-Duluth and (2) UMN-TC medical students who participated in RPAP and (3) UMN-Duluth and (4) UMN-TC students who did not participate in RPAP. UMN medical students complete their first two years on either campus; they can apply to RPAP for their third year. Non-RPAP students spend most of their third- and fourth-year rotations in the Twin Cities metropolitan area. RESULTS: The UMN-Duluth and RPAP students were most likely to select a rural location and primary care practice. UMN-TC, non-RPAP students followed national trends, choosing predominantly metropolitan and specialty practices. CONCLUSIONS: RPAP and UMN-Duluth provide significant, complementary educational programs that lead more graduates to choose rural and primary care practices. Efforts across the nation to address the crisis in rural primary care should build on these successful efforts.

Blunted opiate modulation of hypothalamic-pituitary-adrenocortical activity in men and women who smoke.

OBJECTIVE: To examine the extent to which nicotine dependence alters endogenous opioid regulation of the hypothalamic-pituitary-adrenocortical (HPA) axis functions. Endogenous opiates play an important role in regulating mood, pain, and drug reward. They also regulate the HPA functions. Previous work has demonstrated an abnormal HPA response to psychological stress among dependent smokers. METHODS: Smokers and nonsmokers (total n = 48 participants) completed two sessions during which a placebo or 50 mg of naltrexone was administered, using a double-blind design. Blood and saliva samples, cardiovascular and mood measures were obtained during a resting absorption period, after exposure to two noxious stimuli, and during an extended recovery period. Thermal pain threshold and tolerance were assessed in both sessions. Participants also rated pain during a 90-second cold pressor test. RESULTS: Opioid blockade increased adrenocorticotropin, plasma cortisol, and salivary cortisol levels; these increases were enhanced by exposure to the noxious stimuli. These responses were blunted in smokers relative to nonsmokers. Smokers tended to report less pain than nonsmokers, and women reported more pain during both pain procedures, although sex differences in pain were significant only among nonsmokers. CONCLUSIONS: We conclude that nicotine dependence is associated with attenuated opioid modulation of the HPA. This dysregulation may play a role in the previously observed blunted responses to stress among dependent smokers.

Early introduction to pregnancy care and delivery for medical students.

BACKGROUND AND OBJECTIVES: We developed a curriculum designed to expose first-year medical students to the longitudinal experience of prenatal care and delivery. The curriculum included reinforcement throughout clinical training to increase their knowledge of pregnancy care and to encourage inclusion of pregnancy care in their future family practice. METHODS: The program was implemented at the University of Minnesota Medical School Duluth, and titled the Obstetric Longitudinal Program (OLP). It provided continuity care experiences among medical students, family physician preceptors, and obstetric patients. Students were enrolled by lottery. Students who were not selected in the lottery to participate in the program served as a control group. All students completed knowledge and attitude tests before and after the program. RESULTS: Compared to the control group, OLP participants had higher knowledge scores at the end of the program and expressed greater likelihood to include deliveries in their future practice. The OLP was well received by all participants. CONCLUSIONS: The OLP provided a continuity of care experience for first-year medical students. Further studies are needed to determine if such early medical education experiences actually change the future practice of family physicians.

Service learning in rural communities. Medical students teach children about the brain.

Incorporating service learning into a medical school curriculum can have significant benefits for both the students and the communities they serve. The University of Minnesota Medical School-Duluth Campus has integrated an established neuroscience literacy program into a community service requirement for second-year medical students. Since 2005, medical students taking part in the program have made presentations about the brain and how it works to more than 10,000 elementary school students throughout Minnesota and northwestern Wisconsin. This article describes this initiative and the potential benefits to both the medical and elementary school students.