PRIMARY CARE EXPERIENCES—UNDERGRADUATE

For the purpose of this review, primary care is defined as first contact care that is comprehensive (promotive, preventive, curative, rehabilitative), coordinated, and provides continuity of relationship between patient and physician. This is the definition originally proposed by Alpert and Charney in 1974. ¹⁶ The Institute of Medicine in its report “Primary Care in Medicine: A Definition” adds the concepts of accessibility (in time and location) and accountability of services rendered by a team. ¹⁷ These additions are certainly consistent with our intent.

Primary care educational experiences are found throughout the undergraduate and graduate medical education experience in the United States. The major impetus for the development of these programs has been the support of federal funds under the various Health Manpower Development and Training Acts beginning in 1972. The major vehicle for undergraduate primary care exposure has been the “preceptorship.” The definition of a preceptorship used by DHHS to guide its program support efforts is “at least two weeks continuously under the supervision of a physician preceptor in the practice of primary care outside the academic medical center.” ¹⁸ In a survey of 95 medical schools conducted as part of its preceptorship program evaluation activities, DHHS determined that in 1976-1977, of 92 medical schools responding, all but 1 indicated that they had a preceptorship program that met this definition, and 73 of 137 such preceptorship programs were federally funded. The federally supported programs were more likely to emphasize primary care, preventive medicine, and location in underserved areas than those sponsored solely by the medical school. Overall program evaluation indicated that student satisfaction was directly related to the amount of “desired hands-on experience that was actually received” and that more than 50 percent of students felt that such an educational experience assisted in clarifying their preference for a specialty, size of community, and form of practice. Seventy percent of students selecting family medicine had had one or more preceptorship experiences, but this correlation was felt to represent student self-selection rather than the fact that the preceptorship was a critical incident in specialty or location choice. In addition, the effective structural variables in the preceptorship could not be identified.

Several types of perceptorships have been implemented and documented. In one type the majority of the student's time is spent in the clinical setting with a physician and the other time is variably scheduled for a seminar on community health issues, a placement in a community health agency, or work on a community health project. Morrison ¹⁹ describes such an experience for a psychiatry clerkship. Since 1979, the American Medical Student Association (AMSA) has run a preceptorship program for National Health Service Corps scholarship recipients on behalf of the Corps. Medical and dental students are placed for 4-8 weeks with NHSC physicians in Corps practice sites in health manpower shortage areas. Most students are at the clinical level and the majority of their time is spent in preceptorship relationships with the NHSC physicians in their clinical practice. They are also assigned a small community project, usually clinically related, performing tasks such as developing health education materials or organizing a screening program. Preclinical student placements involve “shadowing” the clinician and a larger-scale project effort often involving community assessment. The goals for these preceptorships are acclimation of the scholarship recipient to the underserved setting and exposure to a primary care physician role model. More than 800 students have been placed in the past 2 years.

Buttery and Moser ²⁰ describe a combined community and family medicine clerkship in which 5 half-days per week are spent in the physician's office, 2 half-days in a structured seminar on the epidemiology of three clinical entities, 1 half-day in the ER, and 1 half-day in a public health agency. While the clinical portion of this preceptorship was evaluated accoming to traditional performance parameters, the student's performance in the seminar was evaluated on the basis of “participation.” Student followup over a several-year period showed an increasing frequency of selection of family practice residencies by students taking the clerkship.

A community-based medical education experience was offered through the Appalachian Health Services Manpower Development Project out of the University of North Carolina. ²¹ Fifty-five percent of the student's time was spent with the preceptor, either in the office or hospital; 5-10 percent of time was spent in a “nonhealth related” community service; 15 percent in “other community health services,” and 10 percent time on a student project. Evaluation showed an increased awareness among students of community needs. Fourth-year students preferred the clinical experience and younger students the community experience. Students felt 6 weeks was long enough, while clinical preceptors felt the program should be at least 8 weeks in length.

The Upper Peninsula (UP) program of the Michigan State University (MSU) College of Human Medicine described by Werner et al. ²² presents a complete revision of a medical school curriculum stressing primary care as the unifying thread of all training. Located in a remote site (the Upper Peninsula of Michigan) and taught by a special primary care faculty and community physicians, this 10-students-a-year program uses separate admission criteria and evaluation standards that assess success in relation to the goal of encouraging primary care practice in remote sites. The first graduating class showed equivalent performance on standard evaluation measures to other MSU students not in the special program, and 8 of 10 UP students selected a primary care specialty, all in a rural location. The Beersheva Experiment in Israel ²³ and University of New Mexico Primary Care Curriculum ²⁴ did likewise build an entire medical education program around the needs for primary care in a given area.

Thus, with notable exceptions involving major curriculum revision, preceptorship programs have generally been the most common vehicle for the introduction of primary care in the community to undergraduate medical students in the United States. The goal of federal programs has generally been exposure of students to underserved communities in order to see what it would be like to practice there. Medical-school-sponsored programs have generally focused on exposure to primary care physicians, largely family physicians, practicing in the community. While increasing numbers of medical schools require an ambulatory care clerkship for fourth-year students, many of these required experiences are still in traditional hospital OPD's and offer predominantly ER and subspecialty clinic experience. The opportunity for continuity is often dependent on the practice organization of the medical center ambulatory care services. The degree to which primary care is provided there determines the degree to which students get a primary care experience rather than merely an ambulatory care experience. Few preceptorships offer systematic instruction in principles of community medicine or the team approach, and the preparation of practitioners for their role as preceptors is variable.

PRIMARY CARE EXPERIENCES—GRADUATE

The surge in graduate medical education programs for primary care is a relatively recent phenomenon in the United States, though Stoeckle ²⁵ recounts a period between 1900 and 1940 when residents at Massachusetts General Hospital spent nearly one-third of their time in the OPD because there were 2-3 times the number of outpatients to be seen daily as there were beds in the hospital. He maintains that the hospital's economy and work have determined the content and sequence of residency training, rather than any educational considerations.

The specialty of family medicine was created in 1969, and, with strong federal financial support, residency programs mushroomed from 15 in 1969 to 364 in 1979. Most medical schools now have a department or division of family medicine, and nationwide about 13.6 percent of graduating students are now selecting family medicine for residency training.

Family medicine programs have tended to stress the principles of primary care elucidated in our original definition. This usually includes training in internal medicine, pediatrics, psychiatry, surgery, and OB/Gyn in a hospital setting (frequently a community hospital) as well as a continuity of care experience in a “family practice unit”—a model practice developed for the residency in which faculty and residents, often in a team organization with other health professionals, serve a defined population. The family practice unit may be community-based (off-site) or may be hospital-based. In some institutions, the family medicine unit serves as the outpatient service for the hospital. The curriculum stresses comprehensive care for the patient in the context of his family, psychosocial skill building to maximize the effectiveness of stability of the doctor-patient relationship, and a variable amount of attention to issues of community medicine.

Donsky and Massad ²⁶ conducted a survey of 122 family practice residency programs in 1978 to determine the extent to which formal concepts of community medicine were taught. In the introduction to their study, they point out that the accreditation requirements for family practice residencies indicate that “principles of epidemiology should be taught; community medicine should provide the resident with an approach to the evaluation of the health problems and needs of a community and to the improvement of resources to meet community needs more adequately.” Of 39 percent of the programs responding to the survey, only 38 percent indicated that they taught techniques for evaluating the health care needs of a community. Thirty-six percent taught issues and strategies involved in the organization of health services to meet community needs. The authors concluded that “community medicine” is taught more often as context than as a set of skills to be learned by an effective practitioner.

In 1979 Rosinski reported on his study of the 13 residency programs in primary care internal medicine and pediatrics funded by the Robert Wood Johnson Foundation. These programs and six residency programs funded by DHEW contracts in 1973 (some of which were the same) were the precursors of the programs in general internal medicine and general pediatrics that increased dramatically (from 63 to 109) during the period of 1976-1980 with the impetus of federal funding under PL 94-484. They stressed the development of a primary care experience for internists and pediatricians seeking to become primary practitioners. Most were based in academic health centers and utilized converted hospital OPD's or group practices for the resident continuity experience. In Rosinski's study of the Johnson programs, he found that only two programs provided an opportunity for residents to take nonclinical electives. One allowed 3 months of electives with weekly seminars in epidemiology, environmental health, sociology, political science, and quality of care assessment. Another offered elective opportunity to learn office practice management, sex therapy, decision theory, and behavioral science teaching. The overall evaluation of the programs was variable, but a consistent dissatisfaction was noted when the practice site was poorly organized. Residents expressed a desire for more structured approaches to the learning of primary care. ²⁷

After the inital contract period, a major federal grant program was launched in 1976 in support of general internal medicine and general pediatrics residency training. To be eligible for federal funds, programs had to meet certain criteria:

1.

Twenty-five percent of residents' time had to be spent in a continuity ambulatory care practice over 3 years (for at least 9 months in each year).

2.

Behavioral science teaching had to be integrated into the residency training.

3.

The practice site had to be organized to assure smooth provision of primary care services.

4.

The team approach was encouraged.

5.

The introduction of “nonclinical” subjects related to primary care, e.g., epidemiology, organization of health services, health economics, etc., was encouraged.

Though no systematic assessment has been done of the teaching of these “nonclinical” areas, informal data appear to indicate that most are seminars on a weekly or monthly basis; some are elective opportunities in community-based agencies or projects, but there is little systematic teaching of a curriculum in community medicine. While some general pediatric and general medicine residencies offer the continuity experience in a community-based practice site, the vast majority feature hospital-based practice models.

An exception to the hospital-based continuity experience and the low emphasis on community medicine has been the residency program in social medicine at Montefiore Hospital. ²⁸ Started in 1971 as an integral part of the medical program at the Martin Luther King Health Center in the South Bronx, the program was designed to train physicians as members of health teams for inner-city practice in underserved areas. Up to 5 months of time is made available for social medicine electives during the 3 years of residency, and a regular Tuesday night curriculum in social medicine is offered. Over the years, there has been a trend toward increased structure for this social medicine time.

There is now a core curriculum in social medicine, including epidemiology, organization and financing of health services, and community assessment. All residents will be expected to take part in the curriculum and complete a required social medicine project. While efforts are being made to further integrate social medicine and clinical teaching, the lack of administrative control over the practice site creates obstacles to developing needed practice systems. Werblun describes a similar evolution towards a more structured curriculum in community medicine in the University of Washington family practice residency program. ²⁹

To meet a perceived need for primary care physicians with community medicine or primary care research skills, a small number of primary care residency programs in pediatrics, medicine, and family practice have begun to offer joint residency training in both a primary care specialty and in preventive medicine. For example, the University of Utah has a joint program in family medicine and preventive medicine. Montefiore offers a Master's in Public Health degree with a clinical residency program, and residency programs can be combined with master's programs in community medicine at Utah, community health at Rochester, and business/public administration at the Wharton School, University of Pennsylvania. In addition, postresidency fellowship opportunities are increasing in individualized programs of health administration, health services research, management or health policy—for example the Johnson Clinical Scholars and recently the Kaiser Fellowships in Epidemiology (Beth Israel). However, with these few exceptions, residency training efforts in primary care have focused largely on the teaching/learning of primary care as defined by Alpert and Charney.

COMMUNITY “ORIENTED” EDUCATIONAL EXPERIENCES

While primary care has joined the vocabulary of medical education, community is not a commonly used word in educational course titles in medical schools or in residency program rotations. The most recent introduction of the community to medical education in the United States began to a great extent during the ferment of the 1960s. Medical students turned towards the community for “relevance” and an opportunity for “service.” Clinical faculty were largely uninvolved in this trend and certainly avoided its incorporation into core medical education offerings. Rather, faculty rationalized medical school activity in the community because it was a “living laboratory for research,” ³⁰ a laboratory in which the medical school studies certain problems.” ³¹ The mission of the medical school in the community was thus defined by one segment of the academic community—the students—as a “service” and by the other—faculty—as “research.” Because of the nature of the times in which these positions were drawn and the political turmoil that often characterized the involvement of medical schools in the delivery of health services in or to “the community” during the 1960s, the development of community-based or community oriented medical education activities has remained controversial and thus problematic. In 1963-1964 the Student Health Organization (SHO) was begun in Los Angeles and Boston. This interdisciplinary group of health profession students shared concerns about social issues and the role of the health professions in addressing them. In 1966 the California SHO placed more than 90 students in rural and urban settings throughout the state with the financial support of OEO and the University of Southern California. The following summer, similar student health projects in Chicago, New York, and California placed more than 250 students of medicine, nursing, dentistry, law, etc., in community service projects. Madison ³² describes three goals for the SHO community project in the South Bronx, goals that generally characterized these programs:

• to provide an educational experience in community medicine;
• to stimulate community action for social change; and
• to provide direct services to community residents.

Different groups of student participants assigned different priorities to these goals. Because the projects were organized by students, the goal of community action became preeminent. Expectations were high for seeing significant impact in the community during the project period. When this did not occur over the few weeks allotted, frustration and disillusionment set in among activist students. The role of students in direct service remained unclear, as most were not yet clinically trained. The community medicine educational goal for the project remained, but rather than pursuing a formal course of learning community medicine skills, students, especially the politically radical, opted for “sensitization” to community needs and discussion and debate of strategies for change. Madison quotes Bronston and McGarvey writing of the 1966 California project:

The most exciting idea that came from the total project was that the students had the ability to establish their own health school in the great tradition of the renaissance university. Retaining the ultimate initiative, the students decided on what they wanted to learn, who they wanted to learn from, and what they wanted to experience. ³²

While this excitement and its resulting commitment supported the development of a strain in medical education that has persisted to the present, the ethos of the learner defining “what community medicine is, who will teach it, and what will be experienced” has persisted, to my mind, to the detriment of true skill-building for the practice of community medicine, certainly the kind required in COPC.

The notion that community medicine is experiential, politically activist and change-oriented, while the rest of medical education, especially mainstream clinical medicine, is academic, politically conservative, and supports the status quo has served to set community medicine apart from the mainstream of medical training and practice. In many medical schools, student enthusiasm for “service opportunities” and the desire of community medicine faculty to avoid the stereotyped rigidity of traditional medical school faculty probably contributed to community medicine being seen as without discipline, representing an attitudinal, contextual learning rather than a set of skills to be learned, practiced, and integrated into clinical medicine.

In the 1970s the student projects changed as the American Medical Student Association (AMSA) assumed a leadership role among student health organizations and SHO broke apart. In 1969, the Student American Medical Association (SAMA, now AMSA) began its medical education and community orientation (MECO) program. Students spent 4-8 weeks in a community, initially based at a community hospital (arranged with the hospital administrator) and later with a private practitioner. Most students were preclinical, and work was almost entirely project-related—on a project identified by the sponsor. This program continues, and currently places about 400 students a year in 16 states. It's goal has been increasing community awareness and community service. AMSA's Appalachian student health projects in 1969-1970 and the further expansion of the MECO program into a variety of summer programs, developed in conjunction with community leaders and in service of their identified needs, gave somewhat more structure to the student projects, though the stress was still on experiential learning and nonclinical service. Departments of community medicine became considerably weakened on medical school campuses in the late 1970s. Their missions became diffuse, and primary care clinical experiences (preceptorships) in the community, having federal support, tended to supplant the community experiences offered by these departments. Students could now enter “the community” by doing a preceptorship with practicing doctors who were already there and under the auspices of the mainstream clinical disciplines, not just through experiences sponsored by departments of community medicine. These departments and their work consequently lost some of their attraction for students.

Medical education in the community remains a source of confusion for students and faculty alike. Many “community oriented” students, especially activist ones, see structured learning in the community as “using the community” and as research that must be balanced with providing a service. Most faculty remain inexperienced in design and implementation of organized experiential learning activities outside school walls, especially those integrating clinical and community medicine.

TRAINING IN PRINCIPLES AND SKILLS OF COMMUNITY MEDICINE

There were and are some notable exceptions to the experiential, sensitizing focus of “community oriented” educational experiences in community medicine. McGavran ³³ proposed a model for the scientific diagnosis and treatment of the community as a patient with its own health status and health needs. The University of Kentucky community medicine program, from its inception, sought to train students to study and analyze the health status of the communities to which they were assigned. A required 6-week senior clerkship featured an analysis of community health needs and service availability. Advanced electives in community medicine focused on epidemiological studies of community health problems. ³¹

Schwarz ³⁴ describes an integrated course in preventive and community medicine in Australia spanning the forth, fifth, and sixth years of medical education. The course combines formal training in the skills of community medicine with exposure to principles of prevention in a rotating assignment to general practices along with an extended epidemiologic investigation as requested by a community.

Geiger ³⁵ describes an intensive and sophisticated graded curriculum in community medicine designed to prepare the graduates of the Sophie Davis School of Biomedical Sciences in New York to be primary care physicians in inner-city, underserved areas. Combining field work, classroom work, community health diagnosis, and problem-solving, the program seeks to train primary care physicians who are clinicians, community health promoters, researchers, and change agents. Because students in this program must complete their last 2 clinical years in five rather traditional medical schools, the integration of this community medicine training with clinical practice is not yet possible within the. Sophie Davis setting.

Bennett describes the evolution of his approach to community medicine training of medical students and community health workers in Africa over the past 20 years. ³⁶ Using an interdisciplinary faculty (biomedical, community medicine, and clinical) in “teaching health centers” and “teaching health districts,” students assume progressively more responsibility for design and implementation of community diagnosis in conjunction with the community and other health workers.

Finally, Deuschle and Bosch ³⁷ define a collaborative model for primary care and community medicine practitioners. The “service” role of the community medicine doctor is seen as the planning, development, and evaluation of health services for populations, identifying problems through epidemiology and solving them via better organization of health services— primary, secondary, and tertiary care. Morrell and Holland favor such collaboration and describe the link of epidemiologists and primary care faculty in research efforts within a department of community medicine in London. ³⁸ Kark and colleagues ³⁹ describe a field workshop offered at their health center in Jerusalem to train practicing health professionals to integrate epidemiology and primary care practice.

These and other programs clearly define the specific training needed for the practice of community medicine, but for one reason or another this training is rarely conducted in conjunction with training for primary care in primary care service settings. One exception appears to be the model described by Guerrero in Colombia in which primary care delivery sites are used as the focal points for graded teaching of clinical, community, and preventive medicine to medical and nursing students. ⁶

TEAM APPROACH AND COPC

The team approach has been a feature of educational experiences within each of the categories outlined above. The team concept really came into its own with the development of primary care practice forms. The complexity of the task pointed out the need for a coordinated team of different health professionals. Kindig ⁴⁰ traces the evolution of the health team concept from its inception through the OEO period into the early 1970s. The Institute of Health Team Development funded by the Johnson Foundation at Montefiore Hospital and Medical Center, the Office of Rural Health at the University of Nevada, and others have demonstrated models for faculty training and student education in interdisciplinary team concepts and methods. ^{41 , 42} Again, a federal grant initiative in the early 1970s fostered wider development of educational models for health team development. With the decline in federal funds, the numbers of formal team educational programs have declined, but the concept has been adopted in legislation supporting the development of new health professionals, primary care residencies, and general curriculum development initiatives.

The team approach has, like “community oriented experiences,” taken on a slightly political flavor, connoting less hierarchical forms of interprofessional relationships. The use of applied behavioral science techniques for team building requires explicit attention to concepts slightly foreign to the health professional as a focus for education, topics such as group process, conflict management, leadership and authority, and communication skills! By failing to focus on the team as a work group, many team development efforts have assumed the role of providing interpersonal or group support and have been discredited as “touchy-feely” exercises that take valuable time away from the task at hand—delivery of health services.

Thus, while the label “team” is widespread, the word has many different meanings. The clarity of goals, role definition, and appreciation of the resources other disciplines may bring to a particular health care task—all critical to a well-functioning team—are highly variable. The need for a team approach to the teaching and practice of COPC is evident and, in my opinion, the educational methods and technology for team practice are well tested and just waiting to be applied in COPC programs. ^{43 , 44 and 45}

The need to integrate the teaching of these different elements of COPC has been articulated in several national reports, including A Manpower Policy for Primary Health Care issued by the Institute of Medicine in May 1978 ¹⁷ and a report on the National Rural Practice Project sponsored by the Robert Wood Johnson Foundation in support of “community responsive practice.” ⁴⁶

DEVELOPING FACULTY ROLE MODELS

Primary care faculty have organized themselves in a number of associations. In the field of family practice there is the Society of Teachers of Family Medicine (STFM); internal medicine has the Society for Research and Education in Primary Care Internal Medicine (SREPCIM); and pediatrics has the Ambulatory Pediatric Association (APA). Members of these groups, both as individuals and in the aggregate, represent some of the more sophisticated and “self-conscious” (in the best sense) educators in institutions of medical education today. Family medicine evolved as a new academic discipline over the past 12-13 years. General internists and pediatricians who have struggled to define a true “primary care orientation” within their parent disciplines are likewise creating new training models. These clinical medical faculty have been exposed to behavioral scientists, educational evaluators, nurses, social workers, and nutritionists, as well as ethicists and philosophers, and have been accepting of them as legitimate teachers of their students and residents. This group of faculty are uniquely open to colleagueship with community medicine faculty and to the inclusion of systematic principles of community medicine such a those espoused in COPC as an integral part of primary care training and practice. Community medicine faculty are increasingly involved in health services research. These faculty and others with clinically related research interests should be open to COPC to further develop their professional domain and area of academic activity.

More traditional internists, pediatricians, and other subspecialists need some appreciation of the role of epidemiology in their practice of medicine. With the advent of screening programs, the demand for planning and regionalization of health services, and the application of principles of clinical research, there is increasing demand on them to learn about the “community” of individuals that are potential users of their services. Though this community orientation may be different from that of practitioners of COPC, the “mind set” can be similar—thinking of the problems of aggregate populations as well as individual patients. This common “context” can facilitate communication about COPC between primary care and specialist colleagues.

In order to prepare faculty for the teaching and practice of COPC, I would recommend the following:

1.

The national professional organizations of primary care faculty (STFM, SREPCIM, APA in medicine and analogous organizations in nursing, health education, and other disciplines) should be introduced to COPC concepts at national meetings of these groups. Training opportunities for members should be made available through CME and special faculty development programs sponsored by these organizations.

2.

Certain health professions institutions with a readiness to implement COPC teaching models should be assisted in the effort. Support should be at the undergraduate level in both medical training and training of other health professionals and most especially at the graduate level in primary care residencies. As in the early 1970s, foundations will need to take the leadership in supporting exploration of new educational models. Grant programs should encourage the collaboration of departments of community medicine, schools of public health, or their analogues with primary care residencies and clinical departments sponsoring primary care clerkships. Such efforts should include faculty development programs in which faculty are trained in COPC (using models like the training workshops of Kark and others) and then actually practice and teach COPC under supervision.

3.

Many schools of public health are increasingly trying to attract practicing health professionals and medical faculty to their programs. Special Master's in Community Health programs could stress training for COPC. Current graduate programs in epidemiology could be reoriented toward COPC, adapting workshop models such as those used by Kark and colleagues in Jerusalem.

4.

National Health Service Corps (NHSC) practitioners are offered 1 half-day a week for continuing education in an area of their interest. In addition, the corps contracts with educational institutions to provide formal offerings 1 day per month for these physicians. Integration of COPC training into these formal programs or offering NHSC practitioners the option of learning this approach in their CME time could help develop not only a cadre of role models for the scholarship and other students placed with such physicians for educational programs, but also will orient a group of future primary care practitioners to COPC.

DEVELOPING ROLE PRACTICE OPPORTUNITIES FOR STUDENTS AND RESIDENTS

Because current reimbursement systems tend not to support community health needs assessment, surveillance, or the health promotion efforts of COPC in the clinical encounter, other sources of support for these activities will be necessary. Foundation support and special arrangements with third parties to test this new practice form in model practices will be necessary. The most logical focus for these initial tests may be:

• family practice centers that can serve as sites for both practice and educational models;
• community-based practices that lend themselves to COPC and that may eventually welcome students and residents into the practice; and
• a selected number of National Health Service Corps practice sites.

Service and teaching COPC centers should be established to permit careful evaluation of all aspects of the COPC approach. It must be stressed that COPC is not a research methodology, but is an expanded concept of the practice of primary care. Thus COPC offers the opportunity to document the effectiveness of community health interventions that could provide support for reimbursement experiments involving physicians and other health professionals in community outreach, health education, and health promotion.

DEVELOPING AN INTEGRATED CURRICULUM FOR COPC

The word community must reenter the vocabulary of medical education. “Community oriented,” “community responsive,” and “community involved” must begin to represent substantive programs and approaches that are understood to expand and improve the practice of medicine. COPC as defined by Kark, is a uniquely appropriate vehicle to end the polarization between segments of the academic community over community-based education. The integration of community medicine skills into primary care practice expands the ability of the clinical practitioner to provide service to the community (users and nonusers), evaluate the effectiveness of medical programs, and eventually provide opportunities for substantive research on health problems conducted with the community, not on it. By overcoming philosophical arguments about the role of medicine in the community, the combined resources of the academic community can be channeled into the development of a new approach to clinical medicine for individual patients and populations.

The training of faculty role models, the establishment of COPC practices, and the integration of the different curriculum components of COPC into teaching programs will provide the basis for a comprehensive educational test of COPC. Support will be needed for planning, testing, refining, and evaluating each aspect of the educational model. Graduate medical education programs in primary care are the most fruitful focus for this activity for many of the reasons mentioned earlier: readiness of faculty, the existence of model primary care practices that can be modified to COPC relatively easily, and the focus on clinical training for primary care, which would be enhanced by COPC emphasis. Students seeking careers in primary care are increasingly more sophisticated educational consumers. While 5 years ago any “primary care” residency program was acceptable if offered at a quality institution, now specific questions are being asked about formal teaching in behavioral science, community medicine, and epidemiology. A program's ability to offer an integrated educational experience will increase its ability to attract excellent candidates for residency and prepare them for COPC practice.

INFLUENCING SOCIETAL VALUES AND THE VALUES OF MEDICAL EDUCATION IN FAVOR OF COPC

It should be remembered that the different elements of COPC are separated in U.S. medical education because they have not been an organic part of the mainstream of medical training in this country. Many of these elements of COPC have become part of medical education because of pressures from different sources outside the medical education establishment. The push for primary care education came largely from federal and foundation initiatives in support of documented societal needs for increased numbers of primary care physicians in underserved areas. The public's felt need was translated into health policy and implemented partially through an educational strategy.

While public demand for health services in the late 1960s and early 1970s centered around needs for traditional primary care for acute and chronic medical problems, times are changing. The self-help movement, emphasis on prevention both in the media and to some extent in federal policy, and the increasing utilization and legitimacy of complementary therapies like meditation, biofeedback, etc., signal a new sophistication among consumers of health services. The public demand is increasingly for “comprehensive primary care services” and for better relationships with health care providers. It has not yet extended to COPC, but as Sidney Kark said, “the community cannot demand what it does not yet know and has not yet experienced.” Any observer of the current cutbacks in health services in neighborhood health centers has noted the increased dissatisfaction of patients who object to declining social, mental health, and outreach services they learned to expect in the 1960s. Patients of private practitioners are increasingly assertive about their rights to certain services and information from their physician.

Thus, one of our action steps must be education of the public to what COPC can offer. To the degree that public concern, expectation, and demand can affect medical practice and medical education, it must be mobilized by publicity about COPC successes elsewhere and by documented evidence of models established and evaluated in the United States. COPC has appeal and offers resources to all segments of the public seeking primary care services.

The current “societal” emphasis on reducing health care costs may be creating a climate more receptive to the scrutiny of new models for the delivery of primary health care services that have long-term potential for improving health status and decreasing cost to the system. This societal value will have an impact on health care institutions and medical schools to an increasing extent. One of the major problems facing these institutions and their teaching hospitals, especially in large urban areas, is what to do about demand for primary care services. For those institutions whose OPD's are becoming overwhelmed by demand, COPC practice offers the potential for enhancing the utilization of community-based primary care centers. For those institutions seeking new models for primary care services that can increase the appropriate use of their existing inpatient and subspecialty capacity, COPC also has promise. Changes in reimbursement for primary care services will be critical to the support of this shift in health care system emphasis.

The systematic study of primary care practice made possible through COPC can offer primary care faculty in the academic institutions the opportunity for clinical research that can add stimulation to the work environment and increase their academic productivity. For practitioners in COPC facilities, the stimulation of this expansion of practice scope can enhance retention and improve quality of practice over time.

The student body is still an important influence on the institutional climate in medical schools. Without the student activism of the 1960s, the community-based and oriented educational experiences that do remain a part of medical education would likely not exist. The enthusiasm of students for primary care has really driven the machinery initially set in place by foundation and federal support for educational model-building in primary care. The fact that 10 percent of the student body of a certain biomedically oriented medical school elected family practice residencies when that school has no family medicine department, division, or teaching program is a sign of the will of students that can override faculty and institutional intent. Introduction of COPC to students through family practice clubs at medical schools, programs of the American Medical Student Association, and selected educational meetings have been an important impetus for educational change.

With all of the emphasis on technology and hospital-centered medicine, we often forget that 98 percent of all patient contacts with a physician occur in ambulatory, primary care settings and do not involve hospitalization. A reorganization of medical practice at the primary care level can have the most profound influence on the health care system. I think that medical education can exert a major influence in support of such a change, for change often comes about as new generations enter a field. As Julian Tudor Hart has said and educators for COPC must echo:

I am asking those young doctors who will be the innovators of their generation to do more than excellent transactional care . . . and begin to explore this new dimension of anticipatory care of whole populations. ⁴⁷

This is the challenge of education for community oriented primary care, and I believe it can be met.

Robert Tranquada

I have approached this assignment from the pragmatic point of view of a medical school dean who presides over the processes of allocation of resources in the academy, those fiscal and space and personnel decisions whose sum makes up the character of the school itself. I must view the subject of education for COPC from this vantage point, because that is where I am.

I bring with me considerable baggage that biases my view as a dean. I have been a chairman of a department of community medicine, I was involved with the Watts Community Health Center, and I have participated in the reorganization of the Los Angeles County Health Services Department from three separate departments to one significant whole, which was probably one of the more unnoticed but greatest ventures in recent times. Moving a very large county health department into a mode that embodied much of what is involved in COPC is no small undertaking.

The department of community medicine that I founded is now almost entirely devoid of anything that might be called community medicine and is concentrating entirely on very sophisticated—not unnecessary, but very sophisticated—epidemiology. The Los Angeles County Department of Health Services has been gradually torn asunder and dismantled towards its more primitive mode of specialized areas of hospitals, mental health, and public health. The Watts Health Center continues to struggle successfully in spite of diminishing federal support.

As a dean, I have to ask myself why this retrogression from so much promise 15 or more years ago and how can more lasting results be achieved from the enterprise in education for COPC. In short, what can we do to ensure that education for COPC can have a significant role in today's medical school training? What can we do?

No matter how dedicated we may be to the cause, we are constrained to operate within the resources made available. Because of the nature of the sources of those resources, our degrees of freedom in shaping their use are practically limited. We must respond to the fiscal and political realities that keep our institutions housed and our programs fed. A moribund institution isn't going to produce anything, much less COPC oriented students. What are the realities then from the dean's perspective?

Dr. Boufford refers to the important effect of student attitudes on institutional climate. As a participant at USC in the days of the Bronstons and McGarveys and the Student Health Organization, I can attest to the veracity of that observation. In my own school, over the past 6 years, in a school dedicated to the production of primary care physicians, 75 percent of our graduates have entered the primary care specialties of family practice, internal medicine, or pediatrics, against a national average of about 52 percent. This year, the indicators are that no more than 55 percent will do so. While this may well prove to be simply an aberrant class, we cannot help but look at the burden of debt at high-interest rates that they are taking with them and speculate that low-earning primary care roles are simply not attractive, in spite of our best efforts. We must face the realities of the economic burdens now shouldered by the majority of our graduates and consider how these realities will influence career choices. All indications are that they will get worse and not better in the next few years.

We in the medical schools continue to struggle to find experienced and capable faculty to staff our primary care programs. The immense growth in these programs, the 20-fold growth that Dr. Boufford mentioned as happening over the past 12 years, has left an enormous gap in the availability of seasoned faculty expert in primary care fields to teach and serve as the very significant role models that we need. Too many of those that are available or that we are able to bring on board are either from other backgrounds or are young products of what must be described as immature and tentative primary care training programs, which have had great difficulty in defining themselves in terms that are clear and understandable. A recent report in the Annals of Internal Medicine on primary care internal medicine programs in the United States ¹ reveals that only 11 percent of the faculty of such programs are specifically trained in primary care internal medicine. Thirty-five percent come from subspecialties and 30 percent come from chief residencies in traditional internal medicine programs. We have a manpower shortage in role models and in teachers.

The accrediting agencies for the primary care programs have concentrated so much on process and staff characteristics of primary care programs that energy has been diverted from the essential task of defining the congnitive values of those specialties in understandable and achievable terms. In the more-or-less global definitions that have been used, the talk about cultural anthropology, sociology, biostatistics, and epidemiology points in a general direction only. There is a need for definition of the field in product-oriented, cognitive, and measureable terms in just the same way that we can define vascular surgery or gastroenterology. Only in this way can we expect the other specialized faculty to come to some understanding of what it is really all about and to increase their respect for the practitioners of these vital primary care areas. More explicit and understandable descriptions of the expected roles of COPC-trained physicians, better standardized curriculum—you will forgive me for that, but I will make the point again—and much clearer translations of the utility of the nonclinical portions of the curriculum are required for those purposes.

Funding is increasingly a problem. Our primary care departments and training programs are all deep in the red. They are supported by reluctant subsidies from the earnings of the rich departments and surreptitious allocations from general funds through the dean's office, which are being questioned more and more. As we move closer to the limits of funding of medical education and justification of these methods, the willingness of other departments to share scarce resources will become increasingly more difficult. The dean's task of supporting these efforts will be more and more subjected to pragmatic considerations, most of which are unfriendly to the charter of COPC.

Funds for subsidizing the settings in which COPC has grown are disappearing. The litany is familiar to you all: The OEO is gone; Community Health Center funding is under increasing attack from the current Administration; block grants threaten many backbone programs to which we are tied; and medical school capitation is dead. The private foundations cannot be expected to pick up all the slack. Faculty resistance remains. We have not yet made our case with the rest of the faculty. We are seen as dogooders who are concerned with special systems applicable only to captive populations or to the disadvantaged, and what does that have to do with real life? The definition of what we are doing remains vague and unclear. Besides, the money well has dried up and where is the incentive? Traditional university and medical faculty appointment and promotion systems do not work well for any but the most outstanding faculty in COPC. Such systems tend to force well-motivated faculty to ignore hands-on issues and to return to the bench or the calculator.

Objective incentives to students who aim for COPC practice do not exist. Wellness care is not paid for, nor home visits, nor nutrition counselors, nor, I am sorry to say, teaching nurse practitioners, nor epidemiologic studies of communities, nor most of the intervention methods that have been mentioned. Unless a program of universal entitlement arrives, this will continue to be the case. This is a very tough reality with respect to incentives for all of us who would move in this direction.

It is a discouraging picture, at least to this dean, and the question, of course, is where do the solutions lie? I am not sure I know where they all lie. What positive actions are most likely to move medical school education for COPC on to a firm foundation? Time obviously doesn't allow a detailed discussion, and I will just briefly outline a few recommendations.

First, we have a powerful ally in that progress in health sciences has brought the personal and community health concerns together as the heart of a viable health care practice mode. Until recent years the primary concern of public health has been infectious disease. Politically, this has been translated into the task of keeping the dirty diseases of the poor away from the thresholds of the rich. That has made traditional public health supportable as a governmental activity at public expense. Today, the most dramatic issues of community medicine affect rich and poor alike. Properly exploited, this reality should enhance the chances of adequate funding for community oriented concerns of COPC.

We cannot rely on that alone. We need a much sharper operating definition of the cognitive requirements of COPC. Even if we are wrong in our first cut at this, sharper definitions will diminish the not totally unearned view in which we are now held as muddle-headed idealists. If we are wrong with our first definitions, we can change them as we learn. Those cognitive definitions must be translated into a clearly defined and more standardized curriculum. We are at a point where I believe that too much room for innovative programs leaves us without any standards against which we can ask to be judged.

We must concentrate on the development of a significant cadre of outstanding teachers of COPC. Two or three or four centers ought to be established with clear mandates, objectives, and well-defined curricula to help us with the preparation of outstanding teachers and to produce the seminal supply for the rest of the country. That is how every strong program in clinical medicine had its beginning, and I believe it must be the foundation if there is to be a strong academic program in COPC.

We must concentrate on the development of clear evidence of the effectiveness and efficiency, the health and economic advantages of COPC. If we can not do this, we can kiss the idea goodbye. Expensive idealism in health care will not be tolerated on any significant scale in the next several years.

We should, effectively, hole up for the winter while these other tasks are being achieved. We should concentrate on preserving only the best programs, which can tide themselves over with modest foundation support. A half-dozen innovative and excellent academic centers nationally are probably all that can be well-supported in the short run. These should be responsible for programs of visitation, seminars, preparation for academic roles, and development of meaningful accreditation requirements for less favored programs.

We must develop models of COPC clearly applicable to circumstances other than the special or marginal populations with which we have done most of our work; middle-class HMOs, group practices, or segments of university practices come to mind as logical places to start. It is a significant challenge. Otherwise, we must consign ourselves purely to a role of applying these principles to captive or disadvantaged populations only. Nevertheless, we must continue to utilize the special settings where nascent or mature programs have evolved.

Finally, we must divorce ourselves from the image of the fuzzy-minded do-gooder and create a well-defined, hard-headed discipline that can evaluate its achievements in other than emotional terms and that is unified by a clear understanding of its boundaries and its central themes. There is a lot of work to do. Times are hard. Stakes are certainly high. Certainly others will differ from what I have said here, but from the perspective of this dean's chair, something akin to the preceding is required if COPC is to come of age in medical education.

Richard Kozoll

I presume that my comments follow Dr. Boufford's and Dr. Tranquada's, because I am a physician in the current practice of community oriented, responsive, centered, or guided medicine. What I do confess to is the leadership of a very unusual community practice. I believe that I am in the practice of community oriented primary care, but I am certain that many of my patients are unaware of it. My board of directors probably suspects it because my revenues rarely exceed my expenses. It is probably my wife who really knows it, because our incidence of uninterrupted suppers rarely exceeds 300 or so per thousand. In fact, you might talk in terms of community oriented life.

Dr. Boufford has identified a number of critical components and categories of preparatory experience for community oriented primary care. However, I do not feel that these really reflect the inventory of knowledge or skills that I need for the day-to-day operation of a rural health system, my community oriented practice.

I have attempted a list. Forgive me for its length, but I assure you that these are all areas of knowledge or skills that I either have developed, learned indirectly, or am in need of. They include clinical problem solving; behavioral intervention, including individual patient counseling and education; personnel management, including salary and wage administration; job description development; motivational and team leadership skills; fiscal management, including budget formulation and monitoring; accounts receivable and payable management and nonprofit accounting procedures; grant preparation and contract negotiation; data systems use; public relations, including the development of informational materials; other marketing skills and media use; public communications skills, which must be adapted for three cultural and language groups; nonprofit corporate board organization and function; knowledge of federal, state, and local agencies and health programs; knowledge of third-party covered services and reimbursement procedures; emergency medical system development and operation; school health service development and operation; clinical protocol development and quality of care evaluation techniques; community hospital organization and medical staff responsibilities; Joint Commission on Accreditation of Hospitals and/or federal program certification requirements for clinics and hospitals; facility financing and construction; other physical plant requirements, including fire safety codes; development of patient education materials; knowledge of other health professions, including licensure or certification requirements, regulations, and professional capabilities (part of the knowledge needed to organize an appropriate health care team); and principles of population medicine, including use of census and vital statistics data, rate determination, and research design.

Perhaps the most important skill of all is personal time management, one I have not yet mastered. These skills are not conveniently offered by any physician-training program in the United States of which I am aware. I agree with Dr. Boufford that the present schism in the United States between public health and medical practice may impede the development of training programs integrating these two different perspectives.

The impediments, I think, are overcome by an appropriately motivated health professional in training, as well as a flexible training program. I know of many others as well. I feel that I was able to overcome them, and I know of many others who did as well. So much then for the knowledge and skill requirements for COPC.

Dr. Boufford has alluded to community role models as an important factor in education for community oriented primary care, and I agree wholeheartedly and have served from time to time in this capacity for student or resident preceptees from the University of New Mexico. I believe, however, that several predisposing conditions must be met for the role model approach to work. First, the students or residents must be activated. They must fully elect the experience. They must be able to participate actively in their own education. They must feel comfortable in interacting with the teacher or preceptor to whom they are assigned. I feel that development of such activated students is the responsibility of training institutions.

Secondly, the student or resident must make an informal contract with the preceptor. The time and economic demands of the preceptor preclude the continuous sort of attention that full-time faculty may be able to provide. The preceptee may need to help out in certain practice situations in order to free up the preceptor for later one-to-one sessions. This sort of trade-off should be negotiated in advance and should not suddenly and begrudgingly occur in the busy practice situation. The structure of the preceptorship should be negotiated early on to the satisfaction of both parties. Awkward inactivity and inappropriate responsibility for the preceptee may be avoided through this negotiation process.

Thirdly, the preceptor must be prepared to share his or her entire life with the preceptee. In this way the preceptor's personality, as well as his or her professional function, influences practice choices of the preceptee.

And, finally, the chosen practice must be stable, successful, and of high integrity. I think both Dr. Boufford and Dr. Tranquada referred to this point. The potential for “turn-off” rather than “turn-on” should be minimized if medical schools are careful in their choice of community oriented practices. The potential for future replication of the practice by the preceptee, I would think, would be enhanced by an early “turn-on” experience, rather than one of a different kind.

I would now like to reinforce the importance of the timing of preceptorships and other community experiences. I think they should begin early. Dr. Boufford has referred to the concept of ideology or perhaps the prevailing attitude of the microsociety of which the medical student is a part. I think this ideology is most flexible in the initial few months of medical school.

Students must leave the classroom, and they must leave the academic center, even for just a month. We have seen examples all around us of community oriented health professionals who participated vigorously during the 1960s in student projects. The approach works. I know it does. I was one of those students. Students identified as being predisposed to community oriented primary care need to be continually reinforced. It is going to be an uphill battle for them. Electives, fellowships, special projects, and further role model assignment must follow. They should be, and they should feel favored in their schools.

The Checkerboard Area Health Systems participates in a unique program at the University of New Mexico, called the Primary Care Curriculum. We were fortunate to have assigned to our health system two students from their initial class and one student of their second class for a 6-month, second-year, rural health rotation. We are gratified that all three of them are coming back during their fourth year and we intend to reinforce whatever preliminary decisions they may have made. I think more of this should take place.

I would also like to make an argument for including more structure in the community preceptorship. I agree with Dr. Tranquada in this regard. I would like to mention that the structure would help not only the preceptee, but also the community preceptor as well. Everybody would be more comfortable, and the students may feel that community medicine is far less alienated from other areas of medical expertise.

Like Dr. Boufford, I am not willing to write off the influence of medical education on physician career choices. The existing community oriented primary care practitioners in conjunction with innovative training programs can, I believe, shape or at least significantly influence the future of American medicine.

Frankly, if we are not practicing, promoting, teaching, or funding the elements of community oriented primary care, what are we waiting for? The alternatives will be wasteful for society, probably transient, and, in my opinion, a lot less fun.