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.

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.

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.