Patti Pagels

Family Medicine Resident Education: An Innovative Model of Community Medicine Training

Introduction: Family Medicine residents benefit from comprehensive training models which incorporate community medicine and population health principles into patient care. This paper describes an innovative Community Medicine (CM) rotation and reports its effectiveness. Objectives of the rotation are to train residents to 1) identify and intervene in community health problems, 2) respond to particular health issues and care for local cultural groups, 3) coordinate local community health resources in the care of patients, 4) focus on underserved population and 5) assimilate into the community and its organizations. Method: Residents (N=21) participated in a longitudinal CM rotation that included 8 weeks (2 blocks) in the first year and 4 weeks (1 block each) in second and third years. Resident activities included several community agency site visits, health education, journal clubs, didactics, community-based participatory research (CBPR) and direct patient care. Selected residents (2 per year) participated in a targeted community action research experience (CARE). Residents completed a pre-test evaluating their knowledge and attitudes of CM (1=strongly disagree; 5=strongly agree). After the rotation, residents completed a post-test and rated their perceptions of whether the curriculum goals were accomplished (1=not accomplished; 5=accomplished). Results: Residents’ knowledge and attitudes improved significantly on most areas of Community Medicine (CM) (p<0.05). All residents reported that the CM rotation increased their knowledge of health promotion activities (5.00). Residents also felt strongly about their ability to locate community resources of benefit to their patients (4.87), care for patients in non-traditional sites (4.86) and assimilate into the community after graduation (4.81). Conclusion: Residents evaluated the CM rotation favorably. Our rotation is a comprehensive model that can be used by other residencies to train community responsive physicians and meet ACGME guidelines. Rotation activities can be tailored to the specific needs of other residencies and their communities.

Community action research experience (CARE): Training family physicians in community based participatory research

Family physicians are optimal candidates to improve access to care and reduce health care inequalities. The Accreditation Council of Graduate Medical Education (ACGME) requires a structured curriculum in which family medicine (FM) residents address population health [1]. Current models of FM training may not adequately prepare physicians to partner with and impact the health of their communities. One way to respond to this shortfall is by training FM residents in community-based participatory research (CBPR). CBPR is an approach that equitably involves community members, organisational representatives, and researchers in all aspects of the research process. Community partners contribute expertise and shared decision-making with researchers [2]. The aims of CBPR are to: increase understanding of a given phenomenon; integrate the knowledge gained with interventions; and change policy to improve the health and quality of life of community members [2]. To achieve successful outcomes, CBPR projects require trained physicians and researchers. An optimal time for training is during residency; however, due to the complexity of the residency structure, it is challenging for programmes to incorporate CBPR in their curriculum. We developed a longitudinal community action research experience (CARE) to train FM residents in CBPR skills to increase their community engagement and interests in practising in community-based underserved settings after graduation. In this article, we provide an overview of the CARE curriculum and evaluate the impact of the programme based on residents’ feedback and accomplishments. Methods

Teaching primary care providers about parent-provider literacy communication

Dear Editor, Reach Out and Read (ROR) encourages paediatric literacy discussions during well-child (birth to five-year old) visits in the United States [1]. The programme includes: integration of book delivery; delivery of anticipatory guidance to parents on dialogic reading; assessment of developmental literacy milestones; and modelling reading by volunteers in clinic waiting rooms [1]. The aim is to improve language skills, cognitive skills and school readiness through shared reading between parents and children. However, primary care (PC) providers are not adequately prepared to communicate with parents about literacy during well-child visits. Rosenthal et al. demonstrated that an intervention utilising didactic sessions, roleplaying and peer feedback can improve Family Medicine (FM) residents’ knowledge, skills and attitudes towards paediatric literacy concepts [2]. Although these training methods can be effective, more experiential training on paediatric literacy promotion and parent-provider literacy communication is needed for PC providers. We pilot-tested a curriculum to improve medical learners’ ability to incorporate paediatric literacy communication into well-child visits. FM residents (n = 30), physician assistant (PA) students (n = 42) and medical students (n = 20) participated in a curriculum of: (1) online training; (2) service-learning opportunities at a local homeless shelter participating in ROR [3]; and (3) objective structured clinical exams (OSCEs) we developed to practise parent-provider literacy communication skills. Standardised patients (6 months–5 years) and standardised patient caregivers (SPCs) were recruited and trained. Stations represented children accompanied by their mother, father, grandmother and non-relative caregivers. Each learner completed two stations: (1) infants/toddlers (<2 years) and (2) pre-schoolers (2–5 years). They were evaluated on their abilities to instruct the SPC how to offer books to patients, provide anticipatory guidance and demonstrate basic communication skills. Learners’ selfperceived knowledge, attitudes and satisfaction were collected preand post-curriculum. We found significant improvements in knowledge of activities which foster a child’s reading/writing skills (p = .0074) and attitudes towards assessing literacy and providing parents with anticipatory guidance (p < .0001). All learners (100%) gave at least one recommendation on age-specific reading and books during the OSCE stations. Few learners instructed SPCs to use dialogic reading skills such as pointing at objects (27.3%; ages 6–12 months) and letters in the child’s name (30.8%; ages 4–5 years). Most (63.6%; ages 2–3 years) instructed the SPC to let the SP choose which book to read and were willing to read the same book multiple times. Only 9.1% recommended nursery rhyme books as age-appropriate reading material for the youngest SP (6–12 months). Despite limitations in skills, all learners (100%) spoke slowly and used words that caregivers could understand for all age groups. Our curriculum was effective at improving paediatric literacy knowledge and attitudes. Previous studies evaluating paediatric literacy training among FM residents [2] have had similar outcomes. Our curriculum added to this by measuring anticipatory guidance and communication skills using paediatric SPs and SPCs. We hope to develop additional OSCE stations to include stations where the SPC has more than one child or needs language support from an interpreter. While our unique population of medical learners may not be the similar to other universities, we hope that sharing our results can raise awareness of the importance of integrating early childhood literacy discussions into well-child visits from birth to 5 years. Yours sincerely.

An Outbreak of Pellagra in the Kasese Catchment Area, Dowa, Malawi

AbstractPellagra is a deficiency of niacin or its amino acid precursor, tryptophan, which presents with the classic four Ds: the characteristic dermatitis, diarrhea, dementia, and eventually death if left untreated. The incidence of pellagra is quite rare presently because of increased awareness and strategies such as vitamin fortification. However, the deficiency is still present in cultures that rely on maize as their primary source of sustenance. We report a recent outbreak in a catchment area in Kasese, Malawi, of 691 cases of pellagra which were successfully treated with niacin supplementation. We present this short report to highlight the importance of educating providers of at-risk populations about this diagnosis and to consider solutions for these populations to prevent further deficiencies.