Ardis Davis

Substance Abuse Units Taught by Four Specialties in Medical Schools and Residency Programs.

Four medical specialty organizations conducted a survey of 294 departments in 98 medical schools and 1,124 residency programs to identify the number and type of curriculum units on substance abuse offered by these specialties. A curriculum unit was defined as a formal block of teaching on substance abuse. A total of 251 (85 percent) of the medical school departments and 828 (74 percent) of the residency programs responded. Of those, 175 (70 percent) of the medical school departments and 479 (58 percent) of the residency programs reported offering at least one curriculum unit on substance abuse. There was considerable variation among the four specialties in the number and percentage of departments or programs reporting such units. Overall, a majority of the units addressed both alcohol and other drugs, were required, and included a clinical component. Evaluations of content and teaching strategies are needed to examine the quality and adequacy of substance abuse training.

Emerging Lessons of the Interdisciplinary Generalist Curriculum (IGC) Project.

The Interdisciplinary Generalist Curriculum Project (IGC) was funded in 1993 by the Health Resources and Services Administration with the goal of developing innovative preclinical generalist curricula in ten of the nations medical and osteopathic schools. The IGC successfully completed two competitive cycles in which ten schools were awarded three-year contracts. Although the long-term goal of the project is to increase the proportion of medical students choosing generalist careers, much has been learned thus far about the processes of curricular change and interdisciplinary cooperation. Drawing on information from school reports, site visits, external evaluations, academic presentations, and annual project meetings, this report presents the emerging lessons learned in the key areas of interdisciplinary collaboration, recruitment and retention of community preceptors, faculty development, and integration of generalist-related components into the four-year medical school curriculum. These lessons should prove useful for other schools embarking upon significant curricular innovations.

ADVANCING THE PRIMARY/SPECIALTY CARE INTERFACE THROUGH ECONSULTS AND ENHANCED REFERRALS

As academic health centers (AHCs) respond to valuebased purchasing, they are embracing a transformed role for primary care. As a case in point, 5 AHCs have formed a collaborative organized by the Association of American Medical Colleges (AAMC) to extend a model developed at the University of California, San Francisco (UCSF) that addresses the referral process between primary care and specialty care providers. This program, known as Coordinating Optimal Referral Experiences (CORE), incorporates 2 EMR-based innovations into the clinical workflow: (1) specialtyand problem-specific templates that provide prereferral decision support to the primary care physician and establish a co-management agreement between providers,1 and (2) “eConsults” which involve providerto-provider asynchronous messaging. With eConsults, the primary care physician sends a focused clinical question to a pre-identified subspecialist who then responds within 48 to 72 hours. The eConsult allows the primary care physician to provide care for the patient directly, provides specialist input in a convenient and timely manner for the patient, and reduces expensive specialty-driven care for minor issues, which in turn frees up the specialist for more complicated patients. Upon completion of each eConsult, both the primary care physician and the specialist receive a productivity (RVU) credit for their efforts. Overall, the model emphasizes and supports the role of the primary care physician as the primary provider for the patient, and emphasizes the rational use of services. The AAMC received a Health Care Innovations Award from the Center for Medicare and Medicaid Innovation (CMMI) to disseminate this model in partnership with UCSF across 5 partner institutions (University of Wisconsin, University of Iowa, University of California San Diego, University of Virginia, and Dartmouth-Hitchcock). With the 3-year grant, each AHC will implement the program in 15 or more medical and surgical specialties. Departments of Family Medicine are deeply involved in this program, and have identified several early learnings.

Title VII and the development and promotion of national initiatives in training primary care clinicians in the United States

The Title VII, Section 747 (Title VII) legislation, which authorizes the Training in Primary Care Medicine and Dentistry grant program, provides statutory authority to the Health Resources and Services Administration (HRSA) to award contracts and cooperative agreements aimed at enhancing the quality of primary care training in the United States.More than 35 contracts and cooperative agreements have been issued by HRSA with Title VII federal funds, most often to national organizations promoting the training of physician assistants and medical students and representing the primary care disciplines of family medicine, general internal medicine, and general pediatrics. These activities have influenced generalist medicine through three mechanisms: (1) building collaboration among the primary care disciplines and between primary care and specialty medicine, (2) strengthening primary care generally through national initiatives designed to develop and implement new models of primary care training, and (3) enhancing the quality of primary care training in specific disease areas determined to be of national importance.The most significant outcomes of the Title VII contracts awarded to national primary care organizations are increased collaboration and enhanced innovation in ambulatory training for students, residents, and faculty. Overall, generalist competencies and education in new content areas have been the distinguishing features of these initiatives. This effort has enhanced not only generalist training but also the general medical education of all students, including future specialists, because so much of the generalist competency agenda is germane to the general medical education mission.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

The four pillars for primary care physician workforce reform: A blueprint for future activity

82 Max has been a member of the Governing Board of the Student Outreach Resource Center (SOURCE) at Johns Hopkins for 3 years. He is a co-leader of his medical school’s Urban Health Interest Group and Family Medicine Interest Group, he sat on the board of the Maryland Academy of Family Physicians Foundation, and he served as a Student Delegate to the National Congress of Student Members of the American Academy of Family Physicians (AAFP). Recently, Max was appointed to a 1-year term on the AAFP’s Commission on Health of the Public and Science and was named a Sommer Scholar at the Johns Hopkins Bloomberg School of Public Health. As a future family physician, Max looks forward to practicing community-based primary care and preventive medicine. He wants to bring innovative models of primary care delivery to underserved communities and provide coordinated, comprehensive, and compassionate care to his patients.

Developing a Practice-Based Research Network by Integrating Quality Improvement: Challenges and Ingredients for Success

Improving patient outcomes in community‐based settings is the goal of both the Clinical Translational Science Award program and practice‐based quality improvement (QI) programs. Given this common goal, integrating QI and outcomes research is a promising strategy for developing, implementing, and evaluating clinical interventions. This article describes the challenges and strengths illuminated by the conduct of a combined research/QI study in a nascent practice‐based research network. Challenges include researchs exclusion of clinic patients who might benefit from the intervention; QI programs’ less uniform approach to intervention implementation; and the need for both academic and clinically relevant products and publications. A major strength is the increased likelihood of both engaging clinical practices in research and developing successful clinical interventions. Required elements for success include identification of enthusiastic clinical research “champions,” involvement of researchers with clinical experience, and adequate funding to support both research and clinical resources and dissemination. Combined Ql/research projects in the practice‐based research environment have the potential to improve and shorten the cycle from good idea to improved clinical outcomes in real‐world settings. Clin Trans Sci 2012; Volume 5: 351–355

A pivotal time for family medicine leadership development.

Effective leadership is one of the most critical and valued assets to successful departments of family medicine and to the discipline as a whole. Leadership positions, including chair roles, pose great challenges and offer extraordinary rewards. At this pivotal moment in history, the Association of

Life change and onset of cancer in identical twins

The relationship of life change to the onset of cancer was studied in 22 pairs of HLA-identical siblings who were discordant for hematologic malignancies. The twin pairs were hospitalized for bone marrow transplantation. Life change was measured using a well-validated instrument, the Schedule of Recent Experiences (SRE). Contrary to our expectations, we were unable to document increased life changes in the sick twins. The timing of administration of the SRE with respect to the transplant did influence reporting of life events. However, regardless of timing of administration, in the period antedating the diagnosis of malignancy the healthy donor twins had increased or equivalent life changes when compared to their sick twins.

MMPI Study of Identical Twins: Cancer Patients and Bone Marrow Donors

23 identical twin pairs, one with a hematologic malignancy, the other a bone marrow donor, completed the MMPI while in the hospital. The validity, clinical, and Repression-Sensitization scales were scored. Paired t tests for the entire group (aged 16 to 67 yr., M = 44 yr.) showed significant differences on Hs, D, and Hy. Males (n = 12 pairs) had no significant differences, while females (n = 11 pairs) had significant differences on Hs, D, Hy, Pa, and R-S. Female patients scored higher on Hs, D, Hy, lower on Pa and were repressors. These findings are congruent with previous research that has yielded psychological differences in people who develop malignancies and those who do not.

INFLUENCING STUDENT SPECIALTY CHOICE: THE 4 PILLARS FOR PRIMARY CARE PHYSICIAN WORKFORCE DEVELOPMENT

Medical students choose a career in family medicine based on the combined influence of many factors. A framework (pipeline, process of medical education, practice transformation, and payment reform) based on the Four Pillars for Primary Care Physician Workforce Development1 provides a logical basis to address student interest in family medicine. Individual departments of family medicine (DFMs) have variable influence and ability to affect these pillars and subsequent student career choice. While the 4 pillars may imply equal impact of each factor on specialty choice, this commentary describes the differential influence of each, and opportunities for greatest return on investment to best meet the nation’s urgent health care needs.