Received date: January 30, 2013; Accepted date: February 20, 2013; Published date: February 22, 2013
Citation: Gimpel N, Pagels P, Roy V, Tullius Z, Billmeier T (2013) Family Medicine Resident Education: An Innovative Model of Community Medicine Training. J Community Med Health Educ 3:197. doi: 10.4172/2161-0711.1000197
Copyright: © 2013 Gimpel N, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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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 medicine; Family medicine; Training; Residency
Family Medicine (FM) resident education needs innovative training models to demonstrate the importance of Community Medicine (CM) and population health training in residency education. At all levels of training and practice, population- and communitybased approaches allow clinicians to examine their quality of care for a specific patient population, make changes in their own system of care and study how these changes affect their practice . The Accreditation Council for Graduate Medical Education (ACGME) requires that FM residents receive a structured curriculum in CM which includes didactic and experiential activities in topics such as abuse, school health, communicable disease reporting, epidemiology, disaster responsiveness and the development and use of community resources to address social determinants of health . These competencies in CM can be met by mastering the following four domains: 1) participation in health activities in the community; 2) sociocultural awareness in care of patients; 3) utilization of the community’s health resources and 4) community participation and assimilation .
Family Medicine (FM) residencies across the United States (US) fulfill the Community Medicine (CM) requirements in various ways. Several existing programs use a Community-Oriented Primary Care (COPC) model  while others offer a global approach by working with various community partners to target a variety of health concerns [5,6]. Some residencies offer training in community health centers , other programs use concentrated CM experiences while others extend their training and offer related degrees (i.e. MPH or MBA) . Most programs have experiences with underserved populations but very few formalized relationships exist between community organizations and educational institutions [3-9]. Few programs utilize longitudinal curriculums while others use block rotations [10-12]. In 2002, Plescia et al. found 89% of FM programs had formal curricula in place to teach CM yet only 24% reported more than one month exclusively dedicated to the CM components . Minimal research describing and evaluating comprehensive longitudinal CM curriculums for FM residents has been published since this assessment. Fisher (2003) described a comprehensive curriculum which combined both an annual block and a semi-longitudinal approach to teaching CM but training did not begin until the second year .
To address these training deficits, we designed a novel Community Medicine (CM) curriculum for Family Medicine (FM) residents. Our rotation incorporates annual concentrated block experiences within a longitudinal curriculum that spans the three-year residency. The purpose of the CM rotation is to train residents to 1) identify and intervene in the community’s health problems, 2) respond to particular health issues of local cultural groups and care for them, 3) coordinate local community health resources for patients, 4) focus on underserved populations and 5) assimilate into the community and its organizations . In this article, we provide an overview of the CM rotation and report its effectiveness based on resident perspectives.
Rotation setting and schedule
Our residency program is collaboration between the University of Texas Southwestern Medical Center (UT Southwestern) Department of Family Medicine (FM) and the Parkland Health and Hospital System. Residents (8 to 10 per year) are recruited to our comprehensive FM residency program which allows for electives, training in culturally competent care for the medically underserved and a targeted track in Community-Based Participatory Research (CBPR).
The Division of Community Medicine, with the support of the Department of Family Medicine, began rotating residents through the Community Medicine (CM) rotation in 2008. In our program, residents participate in two (2) blocks (1 block = 4 weeks) of CM in the first year of residency and one (1) block in each of the second and third years. The rotation is funded internally by the UT Southwestern Department of Family Medicine. Residents participate in CM rotation activities in addition to their regular continuity clinic and required weekly didactics (Table 1). During the first year, residents are exposed to variety of community-based experiences. These include community agency site visits, health education activities, journal clubs and direct patient care (Educational Activities). Residents may choose to participate in specific community projects and research. During the second and third years, residents can tailor their experience with the assistance of the rotation coordinator to obtain the required experiences while exploring their own specific community interests.
|Residency year||CM Rotation Activity||Continuity Clinic||Weekly Didactic|
|PGY1||6 half days/week||3 half days/week||1 half day/week|
|PGY2||5 half days/week||4 half days/week||1 half day/week|
|PGY3||5 half days/week||4 half days/week||1 half day/week|
Table 1: Community Medicine Rotation Schedule.
Our residency partners with a variety of community agencies in the Dallas/Fort Worth metropolitan area to meet both educational and community health needs. A majority of the educational activities designed to meet ACGME standards are met in conjunction with a community partner. The CM rotation benefits from strong existing partnerships with several community sites. For example, residents rotate through North Dallas Shared Ministries (NDSM) and The Monday Clinic (student run free clinic). Residents mentor medical students and also provide care to indigent patients outside of the county hospital system. They provide well-woman exams, hypertension and diabetes care, childhood immunizations and various other disease prevention and health promotion activities. Selected community partners include the Victim Intervention Program/Rape Crisis Program, Mi Doctor, Catholic Charities of Dallas Refugee and Empowerment services, the Resource Center, Children’s Medical Center and a number of nonprofits devoted to health care and attending to the social determinants of health. Experiences are selected and structured to meet ACGME standards.
The Community Medicine (CM) rotation training format includes participation in didactic and experiential activities tied to the ACGME competency areas of patient care, communication, medical knowledge, practice-based learning, system-based learning and professionalism. Residents are required to complete seven (7) categorical education experiences over their three (3) years of training, many of which can be tailored to their particular interests.Throughout their training, residents must: 1) participate in community events; 2) attend site visits with community agencies; 3) provide direct patient care to underserved patients;4) complete online training modules related to community medicine from an online question bank (i.e. MedChallenger©); 5) attend case presentations and lectures related to community health; 6) participate in health promotion and community-based education programs and 7) create a journal club presentation for departmental staff and faculty. Required education activities are linked with ACGME subject areas for competency in Community Medicine (Table 2). Residents may also participate in a Community-Based Participatory Research (CBPR) project. A select group of residents (~2 per year) participate in the Community Action Research Experience (CARE). The CARE offers a longitudinal CBPR track that goes beyond the traditional community medicine rotation by training residents to design and conduct community-based research . CARE residents can modify their rotation to meet the needs of their research or further their training. The CARE was funded by the Health Resources and Services Administration (HRSA D58HP08301) until 2011 and is now supported by the UT Southwestern Department of Family Medicine.
|CM Rotation Activity||#
|ACGME Subject Area Fulfillment||Community Partner
|Community events||2||Community-based disease screening, prevention, and health promotion||La Ventanilla de Salud at the Mexican Consulate
DFW Area Health Education Center (AHEC)
|5||Residents give presentations to Mexican nationals at the Mexican consulate on an assigned health issue with the help of an interpreter.|
|Site visits to community agencies||8||Assessment of risks for abuse, neglect, and family violence||Victim Intervention Program||1||Resident scheduled in hospital unit addressing family violence.|
|Reporting of communicable disease||HIV Outreach/Parkland Mobile Services||2||Screening and referral for STD and HIV at a community clinic and a mobile testing unit.|
|Provision of patient care to an underserved population||3||Disease prevention||Islamic Association of North Texas, Islamic Center of Irving||6||Resident provides health education and care in clinics run by a local mosque.|
|Identifying factors associated with differential health status among sub-populations||Union Gospel Mission
homeless shelters Dallas County Jail Psychiatric Services
|13||Resident provides care to men and women (with or without children) at separate homeless shelters. Resident scheduled in psychiatric unit and covers topics such as female mental health, suicide assessment, full psychiatric assessment and family violence.|
|Online training modules||3||Disease Prevention Community-based disease screening, prevention, and health promotion||Duke University
-Basic Community Health Training
-Medical Screening in a Community Setting
-Working Effectively in Communities
|N/A||Accomplished by didactic and online training.|
|Attend lectures and case presentations related to Community Medicine||4||Environmental illness or injury Disaster responsiveness||Invited experts||N/A||Accomplished by weekly FM lectures.|
|Design, implement and/or participate in non-clinical experiences including health education and disease prevention||5||School health||Fair Oaks School-based Clinics Irving Independent School District||2||Resident works in a FM clinic embedded in a local high school. Resident works with Risk Management Division of local school district.|
|Provide journal club presentation to department staff and faculty||1||Population epidemiology interpretation of public health||UT Southwestern Community Outreach Librarian||N/A||Accomplished by weekly FM lectures and small group discussions.|
*Residents are required to complete didactic and hands-on training in 7 forms of Community Medicine Activities
**Community Medicine rotation activities fulfill 9 ACGME Community Medicine Subject Areas
Table 2: Community Medicine Rotation Activities and Requirements* in fulfillment of ACGME Subject Areas**.
Residents complete two (2) program evaluations using 5-point Likert scales (Tables 3 and 4 for survey items). First, residents complete a pre-test evaluating their knowledge and attitudes of Community Medicine (CM) principles (1=strongly disagree to 5=strongly agree). After the rotation, residents complete a post-test to determine changes in knowledge and attitudes and they rate their perceptions of whether the curriculum goals were accomplished during the rotation (1=not accomplished to 5=accomplished). Residents are required to track their CM activities via an online tracking system coded by topic and linked with ACGME required subject areas. In this article, means and standard deviations are reported. Wilcoxon-signed rank tests were used to determine statistically significant changes in knowledge. Our evaluation was exempted from UT Southwestern Medical Center’s institutional review board approval because it was considered performance improvement.
|Questions||Pretest Mean||Posttest Mean||p-value|
|Understand health and risk assessment||3.81||4.43||0.003|
|Understand role of family physician in health promotion/disease prevention||4.29||4.67||0.021|
|Understand role of family physician in population/community based medicine||3.67||4.62||0.001|
|Understand basic concepts and tools of epidemiology||3.38||4.19||0.001|
|Understand how to use statistics||3.33||4.00||0.003|
|Can identify national and local sources of health data and evaluate effectiveness||3.05||4.19||0.001|
|Understand barriers in preventing health care and improve accessibility||3.71||4.48||0.005|
|Understand health care system and how it affects physician/patient care||3.62||4.43||0.001|
|Understand caring for individuals within context of their families and community||4.19||4.52||0.035|
|Understand the general aspects of community organization||3.57||4.48||0.001|
|Interest in clinical and non-clinical experiences with minority communities||4.10||4.38||0.166|
|Understand environmental and occupational health aspects of community health||3.71||4.38||0.012|
|Understand international health||3.33||4.14||0.011|
|Understand principles of community-based participatory research||3.14||4.38||0.000|
|Understand primary, secondary and tertiary prevention||3.95||4.33||0.011|
|Aware of different models of patient care||3.62||4.29||0.010|
|Recognize the needs of both the individual and the community||4.14||4.48||0.020|
|Cultural beliefs, values and practices which influence self as a cultural person||4.10||4.52||0.003|
|Interest in research/evaluation of community interventions||4.05||4.48||0.007|
|Like to learn more about community oriented primary care/community medicine||4.29||4.38||0.564|
*Wilcoxon signed-rank test
Table 3: Pre- and post-knowledge and attitudes* (N=21).a
Knowledge and attitudes
Residents’ self-reports indicated that their knowledge and attitudes improved on all areas of Community Medicine (CM). Scores increased significantly on all but two survey items (p<0.05). A strong interest in clinical and non-clinical experiences with minority communities and the desire to learn more about community oriented primary care/ community medicine prior to the rotation did not significantly change. Mean change scores indicated that their knowledge improved most on two (2) items: 1) the principles of community-based participatory research (1.24) and 2) understanding the ways to identify existing national, state and local sources of health data and assess their utility and limitations (1.14).
Residents rated the Community Medicine (CM) rotation favorably and self-reported all items as somewhat or completely accomplished during the rotation except for participation in community-based participatory research (3.31). 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).
Our Community Medicine (CM) curriculum is among the most comprehensive curricula published by Family Medicine (FM) residencies and can serve as a model for other residency programs. The detailed structure and evaluation methods (Tables 1-4) described in this article allow other programs to replicate this rotation at their respective institutions. Our rotation is comprised of both didactic and experiential approaches designed not only to meet ACGME requirements, but improve resident attitudes toward community involvement and the knowledge base required of community responsive family physicians. Our novel program can be individualized to meet each resident’s personal interests and training needs while still meeting ACGME requirements.
|Evaluation Items||Mean (SD)|
|Identify community health problems through site visits and/or seeing patients||4.42 (1.03)|
|Incorporate principles of health promotion and disease prevention in rotation||4.68 (0.48)|
|Locate community health resources to benefit my patients||4.87 (0.34)|
|Assimilate into my community and its organization after residency||4.81 (0.75)|
|Participation in community-based participatory research||3.31 (1.54)|
|Participation in service learning opportunities among underserved populations||4.87 (0.34)|
|Increased knowledge of health promotion activities||5.00 (0.00)|
|Observed innovative patient care models||4.45 (1.12)|
|Participated in patient/population care in non-traditional sites (faith-based, school-based linics, etc.)||4.86 (0.35)|
**Scoring done on 5 point Likert scale with 1 = not accomplished, 2 = minimal, 3 = neutral, 4 = somewhat, 5 = accomplished
*Evaluations collected after rotation from January 2009 to February 2012. Number of residents differs from knowledge tests due to off-cycle residents and residents leaving the program
Table 4: Resident Evaluations of overall curriculum goals** (N=31).
Residents evaluated our rotation favorably. We found that residents’ self-reported knowledge and attitudes towards Community Medicine (CM) increased significantly in all areas except for two. Interest in clinical and non-clinical experiences with minority communities and the desire to learn more about CM were both high prior to completion of the rotation. Our residents perceived most activities as somewhat or completely accomplished during the rotation. They reported greater confidence in their ability to use community resources in their own clinics and received a variety of experiences that they enjoyed while increasing their knowledge of CM principles. Not all residents were able to directly participate in CBPR, which may explain their neutral rating of this activity. Published research describes residents’ changes in attitudes and overall satisfaction with their CM and COPC-based training , yet no existing research quantitatively evaluates changes in knowledge of CM competencies among FM residents.
Although our comprehensive curriculum addresses this gap, some limitations may have affected these results. First, evaluation challenges occurred due to staffing changes and off-cycle residents. We used an internal online tracking system to record participation in CM activities; however adherence to the system was not very effective for a variety of reasons. Second, despite creating increased confidence in knowledge of community resources and health promotion, some residents felt (informal feedback) that more responsibilities could be placed on them at some community sites. More involvement with community projects may better train residents how to maximize community engagement thus benefitting the patients in these communities. Third, some residents felt that the experiences could be broadened to include a larger patient spectrum (i.e. more involvement with African American communities) and a greater array of community partners in different subject areas. Although admittedly harder to provide, residents expressed interest in rural and health department experiences which are currently missing from the curriculum. There is also limited resident exposure to occupational/environmental illness and injury, and disaster preparedness which are limited to didactic presentations.
Based on these limitations, several enhancements to this rotation have been made. We recently decided to track residents’ activities using the E-Value® system which is used for the general administration of the residency program. To expand public health knowledge and allow residents to take a more active role with their community partners, CARE residents have the opportunity to pursue a Certificate of Public Health (CPH) through the UT Houston School of Public Health. The first cohort completing this track will graduate in 2013. In order to more accurately evaluate resident knowledge and attitudes and their actual effects on the community, future assessments should include formal feedback from community partners, objective evaluations of resident knowledge and changes to patient care (i.e. direct observation or chart reviews) and our curriculum’s impact on post-residency practice.
Our Community Medicine (CM) rotation is a comprehensive model that can be used by other residencies to train community responsive physicians and meet ACGME guidelines. Exposure to underserved communities can provide opportunities for residents to evolve their cultural competencies and improve patient care in their communities. Rotation scheduling and community partner collaboration can be individualized to other unique residency environments. The CM rotation offers residents the ability to participate in health promotion activities, deliver care in non-traditional health care settings and participate in community-based participatory research and may improve their likelihood of future community involvement.
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