Thomas E. Norris

Longitudinal Integrated Clerkships for Medical Students: An Innovation Adopted by Medical Schools in Australia, Canada, South Africa, and the United States

Purpose Integrated clinical clerkships represent a relatively new and innovative approach to medical education that uses continuity as an organizing principle, thus increasing patient-centeredness and learner-centeredness. Medical schools are offering longitudinal integrated clinical clerkships in increasing numbers. This report collates the experiences of medical schools that use longitudinal integrated clerkships for medical student education in order to establish a clearer characterization of these experiences and summarize outcome data, when possible. Method The authors sent an e-mail survey with open text responses to 17 medical schools with known longitudinal integrated clerkships. Results Sixteen schools in four countries on three continents responded to the survey. Fifteen institutions have active longitudinal integrated clerkships in place. Two programs began before 1995, but the others are newer. More than 2,700 students completed longitudinal integrated clerkships in these schools. The median clerkship length is 40 weeks, and in 15 of the schools, the core clinical content was in medicine, surgery, pediatrics, and obstetrics-gynecology. Eleven schools reported supportive student responses to the programs. No differences were noted in nationally normed exam scores between program participants and those in the traditional clerkships. Limited outcomes data suggest that students who participate in these programs are more likely to enter primary care careers. Conclusions This study documents the increasing use of longitudinal integrated clerkships and provides initial insights for institutions that may wish to develop similar clinical programs. Further study will be needed to assess the long-term impact of these programs on medical education and workforce initiatives.

Teaching procedural skills

ConclusionsProcedures are an important component of the practice of medicine. Students and residents must be trained to perform procedures safely and well. Simultaneously, we must seek consensus on what procedures should be taught, and we must develop better, safer techniques to teach them. Finally, we must develop objective measures of initial and continuing competency for those who perform procedures. We must try to overcome the “turf” battles in this area and focus on what is best for patients, students, and residents.

The Geographic and Temporal Patterns of Residency-Trained Family Physicians: University of Washington Family Practice Residency Network

Background: There is a clear national mandate to increase the proportion of generalist physicians within the medical community and to increase their numbers within rural and underserved urban locations. Little is known, however, about the geographic and temporal career patterns of family physicians or about how these patterns differ by sex and graduation cohort. Methods: Using information from a follow-up survey of the University of Washington Family Practice Residency Network, we analyzed the characteristics of 358 graduate physicians and their 493 practices, including data on geographic practice locations. Results: Two thirds of graduates began their practices in urban locations, and one third initially settled in rural communities. Female graduates were much less likely than their male peers to choose rural practice locations. Few physicians left practices after they had practiced in them for 5 or 6 years. The majority of graduates were still in the practice where they started as long as 18 years earlier. Conclusions: The most important career decision made by the graduate of a family medicine residency involves practice location. Because women are less likely to practice in rural areas, the increasing proportion of women graduating from family practice residencies might presage shortages of rural physicians in the future.

An educational needs assessment of rural family physicians.

Background: A shortage of family physicians persists in rural and medically underserved areas of the United States. We explore the hypothesis that a definable set of educational needs should be addressed for rural family physicians, both during their formal education and as part of continuing education while in practice. Methods: An educational needs assessment questionnaire was sent to 1096 family physicians who had finished residency and entered rural practice within the last 3 years. Six hundred twenty-seven (57.2 percent) of the questionnaires were returned. The demographic characteristics of the respondent physicians and their assessment of the appropriateness and adequacy of their educational process in preparing them for rural practice were analyzed by looking at individual items and groups of items or subject areas. Results: We were able to define successfully a group of items that were important components of rural practice but were not adequately addressed in training programs. These groups included counseling, pediatrics, obstetrics and gynecology, geriatrics, surgery and trauma, medical specialties, surgical specialties, community medicine and management, and a mixed factor that included rehabilitation, behavioral sciences, learning disabilities (in children), chronic childhood problems, and human growth. Conclusions: It is possible to define a group of educational areas not covered adequately by standard family practice curriculum that should be included in preparation for rural practice. If these areas were included in the education of rurally oriented family practice medical students and residents, these physicians would be more adequately prepared to meet the demands of rural practice. If preparation for rural practice is improved, rural communities might be more successful in recruiting and retaining well-trained family physicians.

Student providers aspiring to rural and underserved experiences at the University of Washington: promoting team practice among the health care professions.

In the United States there are shortages of health care providers for both rural and underserved populations. There are also shortages of interprofessional or team-based training programs. To address these problems, the University of Washington’s Area Health Education Center program and School of Medicine offer a voluntary extracurricular program for students in the university’s six health science schools. The Student Providers Aspiring to Rural and Underserved Experiences (SPARX) program is an interprofessional, student-operated, center/school-supported program consisting of a wide range of activities. SPARX supports students interested in practicing among rural and urban medically underserved patients and in interacting with their peers in other health professions schools. A brief history and description of the program are presented, along with results of a survey of students indicating that SPARX reinforces their interest in practice among the underserved and influences their understanding of other health professions. Data on residency choices of medical students who have participated in the SPARX program are presented, indicating that these students are more likely to select primary care residency programs than the average students in their classes.

Developing the Native People for Cancer Control Telehealth Network.

OBJECTIVE We aimed to develop a telehealth network to deliver postdiagnosis cancer care clinical services and education to American Indian and Alaska Native patients, their families, and their healthcare providers. We also sought to identify the challenges and opportunities of implementing such a telehealth-based application for this rural and underserved population. MATERIALS AND METHODS We followed a participatory formative evaluation approach to engage all stakeholders in the telehealth network design and implementation. This approach allowed us to identify and address technical and infrastructure barriers, lack of previous experience with telehealth, and political, legal, and historical challenges. RESULTS Between September 2006 and August 2009, nine tribal clinics in Washington and 26 clinical sites in Alaska had participated in the telehealth network activities. Network programming included cancer education presentations, case conferences, and cancer survivor support groups. Twenty-seven cancer education presentations were held, with a total provider attendance of 369. Forty-four case conferences were held, with a total of 129 cases discussed. In total, 513 patient encounters took place. Keys to success included gaining provider and community acceptance, working closely with respected tribal members, understanding tribal sovereignty and governance, and working in partnership with cultural liaisons. CONCLUSION The telehealth network exceeded expectations in terms of the number of participating sites and the number of patients served. Following a participatory formative evaluation approach contributed to the success of this telehealth network and demonstrated the importance of community involvement in all stages of telehealth system design and implementation.

Use of medline by Rural Physicians in Washington State

Studies have suggested that rural physicians do not use MEDLINE to aid their clinical decision making, and yet rural physicians appear to be a group that would benefit greatly from the use of MEDLINE because of their isolation from libraries and colleagues. This study was undertaken to understand why a population so likely to benefit from the use of MEDLINE is not using it. The study confirmed that rural physicians regard colleagues, reference texts, and journal articles as the most important information sources. However, a surprising number of rural generalist physicians in Washington, 40 percent of respondents, use MEDLINE, and most possess the requisite awareness, resources, and ability to use MEDLINE. Of those who use MEDLINE, 70 percent consider it a valuable clinical tool.

The WWAMI Targeted Rural Underserved Track (TRUST) Program: An Innovative Response to Rural Physician Workforce Shortages.

PROBLEM Too few physicians practice in rural areas. To address the physician workforce needs of the Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI) region, the University of Washington School of Medicine developed the Targeted Rural Underserved Track (TRUST) program in August 2008. TRUST is a four-year curriculum centered on a clinical longitudinal continuity experience with students repeatedly returning to a single site located in a rural community or small city. APPROACH The overarching theme of TRUST is one of linkages. Students are strategically linked to a rural community, known as their TRUST continuity community (TCC). The program begins with a targeted admission process and combines new and established programs and curricular elements to form a cohesive educational experience. This experience includes repeated preclinical visits, clerkships, and electives at a students TCC, and rural health courses, the Underserved Pathway, and the Rural Underserved Opportunities Program (which includes a community-oriented primary care scholarly project). OUTCOMES TRUST was piloted in Montana in 2008. With the matriculating class of 2015, every state in the WWAMI region will have TRUST students. From 2009 (the year targeted admissions began) to 2015, 123 students have been accepted into TRUST. Thirty-three students have graduated. Thirty (90.9%) of these graduates have entered residencies in needed regional specialties. NEXT STEPS Next steps include implementing a robust evaluation program, obtaining secure institutional programmatic funding, and further developing linkages with regional rural residency programs. TRUST may be a step forward in addressing regional needs and a reproducible model for other medical schools.

Expanding clinical medical training opportunities at the University of Nairobi: adapting a regional medical education model from the WWAMI program at the University of Washington.

A major medical education need in Sub-Saharan Africa includes expanding clinical training opportunities to develop health professionals. Medical education expansion is a complicated process that requires significant investment of financial and human resources, but it can also provide opportunities for innovative approaches and partnerships. In 2010, the U.S. Presidents Emergency Plan for AIDS Relief launched the Medical Education Partnership Initiative to invest in medical education and health system strengthening in Africa. Building on a 30-year collaborative clinical and research training partnership, the University of Nairobi in Kenya developed a pilot regional medical education program modeled on the WWAMI (Washington, Wyoming, Alaska, Montana, and Idaho) medical education program at the University of Washington in the United States. The University of Nairobi adapted key elements of the WWAMI model to expand clinical training opportunities without requiring major capital construction of new buildings or campuses. The pilot program provides short-term clinical training opportunities for undergraduate students and recruits and trains clinical faculty at 14 decentralized training sites. The adaptation of a model from the Northwestern United States to address medical education needs in Kenya is a successful transfer of knowledge and practices that can be scaled up and replicated across Sub-Saharan Africa.

ESOPHAGOGASTRO-DUO DENOSCOPY

The need for rapid, accurate, and cost-effective diagnosis of common complaints that arise from the upper gastrointestinal (GI) tract has caused many primary care physicians to add diagnostic esophagogastroduodenoscopy (EGD) to the armamentarium of procedures that they offer in their offices. The use of a scope to visualize the upper GI tract began with Kussmauls passage of a rigid tube into the stomach of a sword swallower in 1868. From that time until the 1930s rigid esophagogastroscopy provided the only available nonsurgical method of viewing parts of the upper GI tract. The rigid procedure had a high risk of perforation and other complications. In 1932 Schuidder and Wolfe introduced a semiflexible gastroscope that substantially decreased the risk of esophageal perforation. By the late 1950s several companies had developed a fully flexible fiberoptic upper GI endoscope that provided much better visibility of a larger portion of the GI anatomy. Finally, during the past 25 years, better illumination techniques and high-quality video cameras have been added to the equipment, making EGD a highly effective diagnostic procedure. 6