Microfinance and poverty reduction: evidence from a village study in Bangladesh

To evaluate the competing claims on the impact of microfinance programs on multidimensional poverty, a village study in Bangladesh was conducted where three microfinance programs had been operating for more than five years. The study found that microfinance has resulted in a moderate reduction in the poverty of borrowers, as measured by a variety of socio-economic indicators, but has not reached many of the poorest in the village. To make microfinance a more effective means of poverty reduction other services such as skills training, technological support, education and health related strategies should be included with microfinance.

ARRA and the HIM workforce

The success of health IT will hinge on how well it is planned and managed. Provisions in the stimulus bill that promote professional support and fund training offer exceptional opportunities to HIM programs, individuals, and the profession.

Providing culturally competent care: residents in HRSA Title VII funded residency programs feel better prepared

BACKGROUND

The Health Resources and Services Administration (HRSA) funds primary care residency programs through its Title VII training grants, with a goal of ensuring a well-prepared, culturally competent physician workforce. The authors sought to determine whether primary care residents in Title VII-funded training programs feel better prepared than those in nonfunded programs to provide care to culturally diverse patients.

METHOD

The authors analyzed data from a national mailed survey of senior resident physicians conducted in 2003-2004. Of 1,467 randomly selected family medicine, internal medicine, and pediatrics residents, 866 responded--403 in Title VII-funded programs and 463 in nonfunded programs (response rate = 59%). The survey included 28 Likert-response questions about residents' preparedness and perceived skills to provide cross-cultural care, sociodemographics, and residency characteristics.

RESULTS

Residents in Title VII-funded programs were more likely than others to report being prepared to provide cross-cultural care across all 8 measures (odds ratio [OR] = 1.54-2.61, P < .01) and feeling more skilled in cross-cultural care for 6 of 10 measures (OR = 1.30-1.95, P < .05). Regression analyses showed that characteristics of the Title VII-funded residency training experience related to cross-cultural care (e.g., role models, cross-cultural training, and attitudes of attending physicians) accounted for many of the differences in self-reported preparedness and skills.

CONCLUSIONS

Senior residents in HRSA Title VII-funded primary care residency training programs feel better prepared than others to provide culturally competent care. This may be partially explained by better cross-cultural training experiences in HRSA Title VII-funded programs.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

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

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

The American Medical Student Association's contributions to advancing primary care

The American Medical Student Association (AMSA) Foundation is the programming arm of AMSA. The AMSA Foundation has administered several Title VII contracts designed to enhance the primary care education, leadership development, and cultural competence of the next generation of physicians, dentists, and other graduate-level health professionals. The authors discuss several AMSA programs developed with Title VII funding: Generalist Physicians in Training; Promoting, Reinforcing, and Improving Medical Education; National Primary Care Week; Leadership Seminar Series; and Achieving Diversity in Dentistry and Medicine. This article summarizes the work of these programs and discusses the impact that decreased funding has had on the training of our nation's future health professionals.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

The impact of Title VII on general and pediatric dental education and training

The authors describe the impact of the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program on the development, growth, and expansion of general and pediatric dentistry residency programs in the United States. They first briefly review the legislative history of the Title VII program as it pertains to dental education, followed by a historical overview of dental education in the United States, including a description of the differences between dental and medical education and the routes to professional practice. The authors then present an extensive assessment of the role of the Title VII grant program in building general and pediatric dental training capacity, diversifying the dental workforce, providing outreach and service to underserved and vulnerable populations, stimulating innovations in dental education, and engaging collaborative and interdisciplinary training with medicine. Finally, the authors call for broadening the scope of the Title VII program to allow for predoctoral training (dental student education) and faculty development in general and pediatric dentistry. In doing so, the Title VII program can more effectively address current and future challenges in dental education, dentist workforce, and disparities in oral health and access to care.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Two decades of Title VII support of a primary care residency: process and outcomes

PURPOSE

To assess 23 years of Health Resources and Services Administration (HRSA) Title VII Training in Primary Care Medicine and Dentistry funding to the New York University School of Medicine/Bellevue Primary Care Internal Medicine Residency Program. The program, begun in 1983 within a traditional, inner-city, subspecialty-oriented internal medicine program, evolved into a crucible of systematic innovation, catalyzed and made feasible by initiatives funded by the HRSA. The curriculum stressed three pillars of generalism: psychosocial medicine, clinical epidemiology, and health policy. It developed tight, objectives-driven, effective, nonmedical specialty blocks and five weekly primary care activities that created a paradigm-driven, community-based, role-modeling matrix. Innovation was built in. Every block and activity was evaluated immediately and in an annual, program-wide retreat. Evaluation evolved from behavioral checklists of taped interviews to performance-based, systematic, annual objective structured clinical examinations.

METHOD

The authors reviewed eight grant proposals, project reports, and curriculum and program evaluations. They also quantitatively and qualitatively surveyed the 122 reachable graduates from the first 20 graduating classes of the program.

RESULTS

Analysis of program documents revealed recurring emphases on the use of proven educational models, strategic innovation, and assessment and evaluation to design and refine the program. There were 104 respondents (85%) to the survey. A total of 87% of the graduates practice as primary care physicians, 83% teach, and 90% work with the underserved; 54% do research, 36% actively advocate on health issues for their patients, programs, and other constituencies, and 30% publish. Graduates cited work in the community and faculty excitement and energy as essential elements of the program's impact; overall, graduates reported high personal and career satisfaction and low burnout.

CONCLUSIONS

With HRSA support, a focused, innovative program evolved which has already met each of the six recommendations for future innovation of the Alliance for Academic Internal Medicine Education Redesign Task Force. This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Commentary: evaluating Title VII investments in primary care training: drop in the ocean, or levee against the flood?

The Title VII primary care programs have been in place for over thirty years to improve Americans' access to primary care clinicians, especially physicians, through community based, primary care-focused education of students and residents, and preparation of faculty. Despite the long investment in these programs, however, U.S. medical students' interest in primary care has reached new lows. So it might seem obvious why the president's Office of Management and Budget (OMB) declared the Title VII primary care programs "ineffective;" But the OMB analysis aggregates these into an overall assessment of 40 separate Health Resources and Services Administration health professions programs. Furthermore the OMB evaluation of the Title VII primary care programs did not consider the outcomes most readily affected by these grants-those on the individual students, residents, faculty, and institutions. Accordingly, it does not reflect the important role of Title VII in building and sustaining primary care teaching over the years, an impact extensively documented in the accompanying articles. The Title VII primary care programs have struggled with diminishing levels of funding even as sources of support for specialized education have flooded into medical schools and teaching hospitals. What is most impressive about the successes of the Title VII primary care programs documented in the accompanying articles is not just the impressive record of accomplishment but that it occurred despite the powerful forces driving subspecialty care. Hopefully, the next generation of policy makers will use this important history to recommit to a national investment in primary care education.This commentary is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Title VII innovations in American medical and dental education: responding to 21st century priorities for the health of the American public

The Title VII Training in Primary Care Medicine and Dentistry grant program has been an engine for innovation by providing funds to develop and implement new curricula, new models of care delivery, and new methods of fellowship and faculty development. During period one, 1963-1975, the disciplines of family medicine and physicians assistants (PAs) first received funding to establish residency programs in family medicine and student training for PAs. Other innovations included interdisciplinary training and curricula in substance abuse and nutrition. During period two, 1976-1991, Title VII funds supported implementation of general dental residency programs. In family medicine, general internal medicine, and general pediatrics, ambulatory care training was expanded with a focus on community-oriented primary care and preventive medicine, as well as curricula in ethics, distance learning, behavioral health, and what is now called evidence-based medicine. During period two, Title VII also helped build the infrastructure of primary care through funding to recruit faculty, to expand training sites into community settings, and to incorporate topics relevant to primary care. During period three, 1992-present, innovations shifted to areas of clinical relevance or national priority, training in the care of vulnerable populations, and design of educational strategies to eliminate health disparities, often through collaborative partnerships between medicine, dentistry, and public health. This article focuses on three areas that reflect much of the current work of Title VII grantees: clinical skills and practice improvement, interdisciplinary models of training and patient care, and care of vulnerable and underserved populations.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

A legislative history of federal assistance for health professions training in primary care medicine and dentistry in the United States, 1963-2008

This article reviews the legislative history of Title VII of the United States Public Health Service Act. It describes three periods of federal support for health professions training in medicine and dentistry. During the first era, 1963 to 1975, federal support led to an increase in the overall production of physicians and dentists, primarily through grants for construction, renovation, and expansion of schools. The second period, 1976 to 1991, witnessed a shift in federal support to train physicians, dentists, and physician assistants in the fields of primary care defined as family medicine, general internal medicine, and general pediatrics. During this era, divisions of general internal medicine and general pediatrics, and departments of family medicine, were established in nearly every medical and osteopathic medical school. All three disciplines conducted primary care residencies, medical student clerkships, and faculty development programs. The third period, 1992 to present, emphasized the policy goals of caring for vulnerable populations, greater diversity in the health professions, and curricula innovations to prepare trainees for the future practice of medicine and dentistry. Again, Title VII grantees met these policy goals by designing curricula and creating clinical experiences to teach care of the homeless, persons with HIV, the elderly, and other vulnerable populations. Many grantees recruited underrepresented minorities into their programs as trainees and as faculty, and all of them designed and implemented new curricula to address emerging health priorities.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Physician assistants and Title VII support

Federal support through Title VII, Section 747 has played an important role in promoting the use of physician assistants (PAs) in primary care and in the growth and institutionalization of PA educational programs in the United States. Federal workforce policy approaches include PAs in strategies to (1) increase the supply of generalist providers, (2) better balance the distribution of providers to rural and medically underserved areas, and (3) improve the diversity of the health workforce. Evidence from several decades shows that, likely because of Title VII program incentives, PAs have met expectations in terms of practicing in primary care specialties and serving in rural and medically underserved areas. Yet, increasingly, market forces and decreasing federal support for Title VII are affecting these trends, with PAs, like physicians, being drawn to specialty practices.There is considerable use of PAs in all practice settings in U.S. medicine. For several decades, PA training programs have demonstrated that they are efficient means of preparing clinicians who provide considerable benefit to society in return for a modest public investment. At the present time, when the climate seems not to favor public subsidy of health professions education, it may be wise for policy makers to consider strategies that address the long-term needs of the health care workforce and the public for primary care clinicians.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Learning from history: the legacy of Title VII in academic family medicine

The current renaissance of interest in primary care could benefit from reviewing the history of federal investment in academic family medicine. The authors review 30 years of experience with the Title VII, Section 747 Training in Primary Care Medicine and Dentistry (Title VII) grant program, addressing three questions: (1) What Title VII grant programs were available to family medicine, and what were their goals? (2) How did Title VII change the discipline? and (3) What impact did Title VII family medicine programs have outside the discipline?Title VII grant programs evolved from broad support for the new discipline of family medicine to a sharper focus on specific national workforce objectives such as improving care for underserved and vulnerable populations and increasing diversity in the health professions. Grant programs were instrumental in establishing family medicine in nearly all medical schools and in supporting the educational underpinnings of the field. Title VII grants helped enhance the social capital of the discipline. Outside family medicine, Title VII fostered the development of innovative ambulatory education, institutional initiatives focusing on underserved and vulnerable populations, and primary care research capacity. Adverse effects include relative inattention to clinical and research missions in family medicine academic units and, institutionally, the development of medical education initiatives without core institutional support, which has put innovation and extension of education to communities at risk as grant funding has decreased. Reinvestment in academic family medicine can yield substantial benefits for family medicine and help reorient academic health centers. This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.

Reflections on the impact of Title VII funding at the University of New England College of Osteopathic Medicine

Title VII funding played an important role in the development of the University of New England College of Osteopathic Medicine (UNECOM). These funds enabled the 90% tuition-funded school to implement a primary-care-based curriculum in its formative years and played a crucial role in the 1995-2005 period of curriculum revision. UNECOM successfully competed for Title VII program funding in Physician Faculty Development in Primary Care, Academic Units in Primary Care, Predoctoral Training in Primary Care, and Residency Training in Primary Care. This funding helped the institution refine its vision and mission as a result of the federal imperatives surrounding primary health care. Securing these funds enabled the institution to jump-start programs with start-up federal funding, expand faculty, access educational innovation by networking with other grantees across the nation, and expand faculty grant-making knowledge and skills via federal technical assistance and grant review processes. Subsequent institutionalization of the resulting innovations may have played a role in UNECOM maintaining its production of primary care physicians, as evidenced by 71% of its 1996-2002 graduates practicing in primary care specialties. The impact of Title VII funding at UNECOM provides an example of how new and existing medical schools whose missions align with federal priorities can use these programs to develop curriculum and resources congruent with their missions.This article is part of a theme issue of Academic Medicine on the Title VII health professions training programs.