Differences in curriculum emphasis in US undergraduate and generalist residency education programmes.

OBJECTIVES: Little attention has been paid to the differential emphasis undergraduate and graduate medical education programmes place on the broad competencies that will be needed for practice in an increasingly managed health care environment. The purpose of this study was to determine differences in emphasis that undergraduate and primary care graduate medical education programmes are currently placing on 33 broad practice competencies, compared with the emphasis they ideally would like to give them, and the barriers they perceive to curriculum change. DESIGN: Subjects were surveyed by mailed questionnaire. A reminder postcard and follow-up mailing were sent to non-respondents. SETTING: US allopathic medical schools. SUBJECTS: Academic deans identified by the Association of American Medical Colleges (AAMC) and generalist (family medicine, internal medicine, paediatrics and obstetrics-gynaecology) residency programme directors identified by the American Council on Graduate Medical Education (ACGME). RESULTS: Findings revealed that residency programmes placed greater emphasis on the study's broad curriculum topics than did undergraduate medical education programmes. Statistically significant differences were found in current emphasis for 12 topics and ideal emphasis for six topics. Both groups identified an already crowded curriculum and inadequate funding as the top two barriers to curriculum change. CONCLUSIONS: The differences in curriculum emphases and perceived barriers to curriculum change most probably reflect the different realities of undergraduate and graduate medical education programmes, i.e. academics vs. a focus on immediate practice realities.

A strategy for the detection and evaluation of unprofessional behavior in medical students. University of California, San Francisco School of Medicine Clinical Clerkships Operation Committee.

The authors describe the first four years (1995-1998) in which the University of California, San Francisco School of Medicine operated an evaluation system to monitor students' professional behaviors longitudinally through their clinical rotations. The goals of this system are to help "turn around" students found to have behaved unprofessionally, to demonstrate the priority placed by the school on the attainment of professional behavior, and to give the school "muscle" to deal with issues of professionalism. A student whose professional skills are rated less than solid at the end of the clerkship receives a "physicianship report" of unprofessional behavior. If the student receives such a report from two or more clerkships, he or she is placed on academic probation that can lead to dismissal even if passing grades are attained in all rotations. Counseling services and mentoring by faculty are provided to such students to improve their professional behaviors. From 1995 to 1998, 29 reports of unprofessional behavior on the part of 24 students were submitted to the dean's office; five students received two reports. The clerkship that submitted the most reports was obstetrics-gynecology. The most common complaint for the five students who received two reports was a poor relationship with the health care team. Four of these students had their difficulties cited in their dean's letters and went on to residency; the fifth voluntarily withdrew from medical school. The authors describe the students' and faculty members' responses to the system, discus lessons learned, difficulties, and continuing issues, review future plans (e.g., the system will be expanded to the first two years of medical school), and reflect on dealing with issues of professionalism in medical school and the importance of a longitudinal (i.e., not course-by-course) approach to monitoring students' behaviors. The authors plan to compare the long-range performances of students identified by the evaluation system with those of their classmates.

Occupational exposures to body fluids among medical students. A seven-year longitudinal study.

BACKGROUND: Medical students may be at high risk for occupational exposures to blood. OBJECTIVE: To measure the frequency of medical students' exposure to infectious body substances, to identify factors that affect the probability of such exposure, and to suggest targets for the prevention of such exposure. DESIGN: Review of all exposures reported by medical students at the University of California, San Francisco, School of Medicine. SETTING: Teaching hospitals affiliated with the University of California, San Francisco. PARTICIPANTS: Third- and fourth-year medical students from the classes of 1990 through 1996 at the University of California, San Francisco, School of Medicine. INTERVENTIONS: A needlestick hotline service was instituted at teaching hospitals affiliated with the University of California, San Francisco, and a required course was created to train students in universal precautions and clinical skills before the beginning of the third-year clerkship. MEASUREMENTS: Reports of exposures made to the needlestick hotline service, including type of exposure, training site, clerkship, and time of year. RESULTS: 119 of 1022 medical students sustained 129 exposures. Of these exposures, 82% occurred on four services: obstetrics-gynecology, surgery, medicine, and emergency medicine. The probability of exposure was not related to graduation year, clerkship location, previous clerkship experience, or training site. Surveys of two graduating classes at the beginning and end of the study showed that the percentage of exposures reported increased from 45% to 65% over the 7-year study period. Thus, the reported injury rates represent minimum estimates of actual occurrences. Human immunodeficiency virus infection and hepatitis were not reported, although follow-up was limited. CONCLUSIONS: Instruction in universal precautions and clinical procedures is not sufficient to prevent exposures to blood during medical training. Medical schools must assume greater responsibility for ensuring that students are proficient in the safe conduct of clinical procedures and must develop systems that protect students so that they can report and learn from their mistakes.

"Bimodal" medical schools: excelling in research and primary care.

The authors studied four "bimodal" medical schools--those ranked in the top 20% by the Association of American Medical Colleges both in production of primary care physicians and in receiving research grants from the National Institutes of Health. A descriptive, anthropologic method was used to describe the cultures of these schools and to determine common factors in their success. The four schools are at the University of Washington, the University of North Carolina, the University of California, San Francisco, and the University of California, San Diego. These common factors ranged from characteristics of the schools to characteristics of their external environments. All four are part of large, state-supported universities. They are relatively new schools in areas of the country that have blossomed in biotechnology, aerospace, and computer industries. The schools' missions, admission committees, and educational programs reflect their dual role: to meet the health care needs of their states and to advance basic science knowledge in medicine. Each state has a strong Academy of Family Practice, and the medical schools have been in the forefront of residency training in this specialty. Federal- and state-funded Area Health Education Centers and private foundations have provided seed money for educational programs in community and rural settings that attract medical students to primary care. Research-intensive medical schools can encourage students to enter primary care specialties if they have strong primary care leaders and programs and if they support medical education programs outside the academic, tertiary-care center. A culture of mutual respect and commitment to community service is also essential to achieving this bimodal success.

The challenge of defining and counting generalist physicians: an analysis of Physician Masterfile data.

OBJECTIVES: The study reviewed methods for measuring the specialty distribution of the US physician workforce. It was hypothesized that current databases and measurement conventions overestimate the number of generalist physicians. METHODS: A descriptive analysis of the American Medical Association (AMA) Physician Masterfile for California was done with different assumptions about the definition of generalists based on primary and secondary specialty information. RESULTS: A rigorous definition of generalist physician that excludes physicians with secondary practices in specialist fields resulted in an estimate of generalist physicians 25% lower than the number estimated by conventional workforce evaluation methods. Physicians who reported practicing in both generalist and specialist fields were more likely to be older, to be international medical school graduates, and to be in solo or duo practice compared with physicians who listed only generalist or specialist fields. CONCLUSIONS: The actual number of generalist physicians in the United States may be less than previously believed. Although the exact magnitude of the "hidden system" of specialists providing primary care is difficult to measure, at least a portion appear to already be counted as generalist physicians by current conventions.

Factors influencing students' choices of primary care or other specialties.

BACKGROUND: Because of the marked decline in the numbers of U.S. medical school graduates entering the primary care fields of internal medicine, pediatrics, and family medicine, medical educators are increasingly interested in determining the factors that influence students' choices of specialty. METHOD: A few months before graduation, the 142 seniors in the class of 1992 at the University of California, San Francisco, School of Medicine, were surveyed about their choices of first-year residency programs. They were asked to rate various influential factors by using a five-point Likert scale. Chi-square analysis was used to compare the students' responses, by specialty choice (i.e., primary care versus other specialties) and by gender. RESULTS: A total of 102 students responded: 50 who were entering primary care specialties, and 52 who were entering other specialties. Three factors were found to significantly influence the students' choices: future income, opportunities to work with new technology, and faculty advisors. Income and working with new technology were significantly rated factors leading toward the non-primary-care fields (p = .031; p = .000), although a total of only 20 students (15 in non-primary-care) rated income as an important factor. A faculty advisor was a positive influence on the students who were entering residency training in the primary care specialties (p = .000). CONCLUSION: That the influence of a faculty advisor was the significant factor in affecting students' decisions to choose primary care suggests that schools can increase the percentages of their students entering the primary care fields by increasing their students' contact with mentors in these fields.

Women's attitudes toward careers in academic medicine at the University of California, San Francisco.

In order to identify the concerns and possible barriers for women considering careers in academic medicine, in 1990 the authors surveyed both men and women medical students, housestaff, postdoctoral students, and junior faculty at The University of California, San Francisco (UCSF). The authors achieved a 58% response rate from students and faculty, a 21% response rate from postdoctoral students, and a 15% response rate from housestaff. Results indicated that women at all levels were less interested in academic careers than were their male colleagues. Concerns about balancing family responsibilities, clinical practice, and teaching in addition to the research required of an academic career were mentioned most frequently. Women, especially those among the housestaff and junior faculty, reported fewer mentor relationships and role models. The authors discuss these findings in relation to other studies and describe what they are doing to foster women's interest and success in academic medicine at UCSF.

Promoting cancer prevention activities by primary care physicians. Results of a randomized, controlled trial.

BACKGROUND: Previous interventions to promote performance of cancer prevention activities have largely targeted physicians in university-based practices. METHODS: We randomly assigned 40 primary care physicians in community-based practices to either (1) Cancer Prevention Reminders, computer-generated lists of overdue screening tests, and smoking and dietary assessment and counseling, supplemented by cancer education materials; or (2) controls. For each physician, we reviewed a random sample of 60 medical records for data about screening test, assessment, and counseling performance during 12-month preintervention and intervention periods. We calculated performance scores as percentage compliance with American Cancer Society and/or National Cancer Institute recommendations. Multiple regression analyses provided estimates of incremental differences in performance scores between intervention and control groups. RESULTS: Controlling for preintervention performance levels, significant incremental differences in performance scores between intervention and control groups (P less than .05) were achieved for nine maneuvers: stool occult-blood test, +14.5; rectal examination, +10.5; pelvic examination, +11.8; Papanicolaou's smear, +30.7; breast examination, +8.7; smoking assessment, +10.2; smoking counseling, +17.3; dietary assessment, +12.3; and dietary counseling, +13.9. Increments for sigmoidoscopy and mammography were not significant. CONCLUSION: Computerized reminders can significantly increase physicians' performance of cancer prevention activities in community-based practices.

Cancer screening by primary care physicians. Can we explain the differences?

BACKGROUND: Physicians perform cancer screening tests less often than recommended. METHODS: Forty primary care physicians were surveyed to assess their knowledge, attitudes, and experiences regarding cancer and cancer screening, and patients' medical records were reviewed to measure physicians' screening rates. RESULTS: Over 80% of physicians believed doctors should urge screening. On average, 23% of their patient visits were scheduled primarily for preventive care interventions. Screening performance scores expressed the percentage of compliance with the American Cancer Society's recommendations and demonstrated the low levels of compliance for six out of seven tests; however, there was substantial variance in performance among physicians. The best predictors of screening performance were (1) the percentage of visits scheduled primarily for prevention (mammography, and pelvic and breast examinations [P less than .05]); and (2) the number of medical journals read regularly (stool occult blood test [P less than .01], sigmoidoscopy [P less than .01], and Papanicolaou smear [P less than .02]). Also, female physicians performed more Papanicolaou smears (P less than .05) and scheduled more visits for preventive care (P less than .001). CONCLUSIONS: A small group of predictors explain large portions of the variance in cancer screening performance.

Community scavenger hunts.

Interns in an urban family practice program are introduced to the communities of their patients through four half-day community visits which include a "community scavenger hunt." Interns are asked to record their observations of the physical, social, and economic environments of the neighborhoods as they walk through several blocks in groups of two or three. These community visits have heightened the residents' awareness of their patients and the neighborhoods they live in.

Physician interest in collaborative research.

A pilot study of more than 400 clinical faculty was conducted in spring 1985 by the Division of Family and Community Medicine, University of California, San Francisco, to identify physicians interested in participating in collaborative research. Six different approaches to collaborative research were defined, and the respondents indicated their "enthusiasm" to each of the approaches and the methodologies that each would involve. Based on response to mail and phone surveys, it is estimated that 40 percent of the clinical faculty have some interest in collaborative research. Their preferences for the approaches were: (1) randomized trials, 63 percent; (2) surveys of patients, 60 percent; (3) evaluation of physician practices, 59 percent; (4) referral of patients for research conducted elsewhere, 54 percent; (5) research involving chart review, 53 percent; and (6) research involving a change in clinical practice, 38 percent. Thus, there is preference for more complex types of studies, but this can create a dilemma for those who wish to stimulate research among unproven investigators.

Teaching community-oriented primary care (COPC): a practical approach.

To improve education in community-oriented primary care (COPC) and to promote its practice in the community, the University of California's School of Public Health in Berkeley and School of Medicine in San Francisco are collaborating in an innovative program in cooperation with several federally-funded community clinics in the San Francisco Bay Area. The School of Public Health designed a COPC track for graduate public health students from various departments of the school who wished to work in community health care. The track includes a seminar given in the spring of the students' first year in which COPC theory is taught and teams of students working with a faculty advisor and a clinic preceptor design COPC projects for the primary care sites. These projects are then implemented in the summer and fall by students who elect to use this experience to satisfy their fieldwork requirement. This paper is a report of the first year's experience with this collaborative effort.