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.

Excellence in physician assistant training through faculty development

Once again, experts predict a shortage of health care providers by 2020. The physician assistant (PA) profession was created in the 1960s to address a similar need. Currently, there are 141 accredited PA training programs in the United States, 75 of them established in the 10 years between 1993 and 2002. Historically, PA education and practice models have been responsive to the ever-changing landscape of health care. It may be the profession's flexibility and adaptability that has enabled it to survive and flourish in a competitive service environment. The growth of new PA programs mandates a need for continuing faculty development, as increasing numbers of educators hail primarily from clinical practice and come equipped with minimal teaching experience. PA faculty development addresses these new recruits' needs to develop model curricula, implement new courses, and enhance instruction-all with the goal of improving both access to and quality of health care.The author describes the impact of Health Resources and Service Administration Title VII, Section 747 (Title VII) contracts in addressing this need. Title VII-funded PA education projects, considered innovative at the time of implementation, included both faculty development workshops that promoted active learning of basic teaching and administrative skills and new curricula designed to enhance faculty teaching in genomics and practice management. These projects and others resulted in enduring professional resources that have not only strengthened the PA community but also enjoyed broad applicability within other health professions groups.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.

Family policy in Germany: appraisal and assessment

The German government spends about euro 185 billion on measures to support families. This amount is above European Union average, but still, families have become smaller and the number of childless couples has increased. This article outlines some of the 145 German policy measures to support families and their purpose. An assessment that takes into account economic theory and empirical studies shows that an increase of monetary incentives could influence the decision to bear a child only moderately. This implies that policy measures alone cannot be held responsible for the entire difference in fertility rates between countries. Cited studies based on surveys among the German and French populations reveal how different attitudes of the population may also play their role in determining the fertility rate of a country.

[The Argentina State railroad and its contribution to science]

In Argentina, the State financed, built, and ran government-own railroads based on recourse to subsidies until the first Yrigoyen administration (1916-1922), which introduced changes and shifted the direction of rail policy somewhat. The Ferrocarriles del Estado contributed to the development of science, created a demand for professionals which helped form the professional engineering field, and, by linking the capitals of central and northern provinces, facilitated both communications and scientific tasks themselves, especially research into diseases endemic to the country.

The history of health care as a campaign issue

The question of whether--or to what extent--it is the responsibility of government to subsidize health care for its citizens has been an issue in political circles for a long time.

The ethos and ethics of translational research

Calls for the "translation" of research from bench to bedside are increasingly demanding. What is translation, and why does it matter? We sketch the recent history of outcome-oriented translational research in the United States, with a particular focus on the Roadmap Initiative of the National Institutes of Health (Bethesda, MD). Our main example of contemporary translational research is stem cell research, which has superseded genomics as the translational object of choice. We explore the nature of and obstacles to translational research and assess the ethical and biomedical challenges of embracing a translational ethos.

Tension and opportunity in post-world War II American psychology

The rapid growth of post-World War II psychology in the United States led to intradisciplinary tensions and opportunities. In this article, I examine these tensions and opportunities in the context of social change from the 1950s through the present, attending specifically to the broad impact of federal funding on psychology. I argue that as psychology became a resource-rich field, it was forced to move from a narrow, parochial stance to a position as a national-level professional player that had to deal with the challenges of mixing science and practice, as well as meeting the demands of non-White psychologists at the national level. The impetus to create a more inclusive psychology has grown in the last three decades of the 20th century and has helped create possibilities for greater richness in American psychology and movement toward a truly international role vis-a-vis emergent psychologies around the world.

[Financing the public health services. 1967]

Federal statistic figures show that the Brazilian States altogether have, in their respective territories, a collection of taxes which is higher than the Union one. The highest collection of the Central Government which is shown at the official statistics is due to the excess of collection of the federal taxes over the ones of the States; this usually happens in five or six states, of which, in 1964 Guanabara and São Paulo were responsible for 91% of this difference. One can not change the present system of competence in Public Health Services in the three levels--central, regional and local--without modifying at the same time the present Brazilian tributary system, where the municipal governments received back in 1962 only 5.6 of the general collection of taxes. Figures from 1955 show that the per capita cost of Public Health Services in Brazil, comprising the three levels, was Cr 123 Cr dollars dollars ( 1.82 US dollars), and in 1962, Cr 827 (US 2.30 US dollars). These three levels of government reserved in 1955, 5.6% of the money spent in its total expenditure for Public Health activities; this percentage declined to 4.5% in 1962. In relation to the sum invested on Public Health government activities, the Union spent in 1962, 36.4% of the total expenses, the States 59.3% and the counties only 5.5%. There is a great disproportion in the distribution of Public Health expenditure among the various Brazilian States, ranging from a minimal percentage over the total public expenses such as the case of Goiás (1.6% in 1964) up to a maximum of 17.2% in Pará in the same year. There is also a considerable variation from one state to another and in 1964 it ranged from the lowest limit of 70 Cr dollars in Maranhão up to 5.217 in Guanabara. If we analyze the per capita expenses of each state with Public Health activities, using 1964 and 1954 figures represented in 1964 monetary values, we can verify that the expenditure of 20 states dropped of 17.2%. One can not know, without an adequate planning, whether theses per capita expenses with Public Health government-owned services should be increased or not. It is not advisable to perform an international comparison; the figures on hand are not reliable due to the lack of a rational public accountancy system.

Patrons of the revolution. Ideals and institutions in postwar behavioral science

This essay argues that shifts in patronage for the postwar behavioral and social sciences were linked intimately to both intellectual and institutional changes. This broad argument comprises two subarguments: first, that there were in fact two distinct, successive patronage systems for postwar social science--not one, as is commonly assumed; and, second, that the first postwar patronage system played a major role in enabling a series of behavioral revolutions and interdisciplinary syntheses across the social sciences, while the second postwar patronage system encouraged the development of specialized concepts, techniques, and technologies within the disciplines. The essay also suggests that the widespread concern among social scientists in the 1970s and 1980s that their fields were fragmenting was at least in part an unintended consequence of the rise of the second system.

The development of municipal general hospitals in English county boroughs in the 1930s

When thinking of spurs to hospital development in the first half of the last century, it would be easy to assume that the greatest watershed was provided by the 1946 National Health Service Act. In this article, however, we focus on an earlier and often overlooked piece of legislation, which had a perhaps equally significant impact on the development of hospitals in England and Wales. This was the 1929 Local Government Act, which changed both the ownership and the focus of many of the largest hospitals in the country. As Robert Pinker has observed, the act “radically altered the percentage distribution of hospital beds in the public sector”. Such observations notwithstanding, municipal medicine in the 1930s has not received the historical attention it deserves, an omission which this article seeks in part to remedy. The terms of the act in respect of hospital development were permissive, and the extent to which local authorities acted had a great effect on the way in which their municipal hospital services developed, and hence the beds and facilities available at the time of the nationalization of the health services. The reaction of local authorities to the act, however, depended partly on their own choices, and partly on constraints over which they had less control.

The big bang. The Hill-Burton Act put hospitals in thousands of communities and launched today's continuing healthcare building boom

The Hill-Burton act of 1946 put hospitals in thousands of communities across the nation and launched a healthcare building boom that continues today. Robert Taft, right, a Republican senator from Ohio, played a large role in making certain that states, rather than the federal government, had maximum administrative authority.

["A model of joint research"? Cancer research and the funding policies of the German Research Foundation and the Reich Research Council in National Socialist Germany]

In 1936 the German Research Foundation (Deutsche Forschungsgemeinschaft) started planning a programme for tumour research. After discussions between representatives of the German Research Foundation, the Reich Health Office and the Ministry of Science and Education about the extent of the scheme, in December 1936 the first scientists received their grants. The scheme was mainly drawn up by the Munich pathologist Max Borst, who was supported by the German Research Foundation's employee Sergius Breuer. Scientific research on cancer was divided into four sections: (1) etiology, (2) diagnosis, (3) treatment, and (4) constitution, disposition, heredity, and statistics. Well-known German scientists were invited to contribute to the scheme. When the Reich Research Council (Reichsforschungsrat) took over power in decision-making on research funding in 1937, cancer research was not seriously affected. Only in 1943, when further restructuring of the Reich Research Council took place, the situation changed through Kurt Blome's becoming the plenipotentiary for cancer research. Blome's position in cancer research was linked with the task of supporting scientific research on biological and chemical warfare. In general, however, the characteristics of the cancer research scheme remained astonishingly constant up to the end of World War II.

[Geneticists in the service of war? The German Research Foundation, the Reich Research Council, and policy changes in research on heredity]

Historical research has hitherto focused on the specific contribution of human genetics research to National Socialist racial hygiene. During the Third Reich this field had a key position and received very substantial financial support from the government. However, this state sponsorship during the Nazi period was not constant, as documents from the most important public funding organizations for academic research in Germany, the German Research Foundation (Deutsche Forschungsgemeinschaft) and the Reich Research Council (Reichsforschungsrat) show. Human genetics saw a reduction in sponsorship as the government shifted its spending towards preparations for the war. Accordingly, many human geneticists and racial hygienists were unable to continue their research or were forced to change the focus of their work. It is also important to note that much of the available funds were concentrated on the Kaiser Wilhelm Institute for Anthropology, Human Heredity and Eugenics. This essay analyzes the institutional context of science policy as well as the dynamics between the science of human heredity and Nazi politics during the war.

[Continuity in personnel--change in contents: German physiologists in National Socialism and in the Federal Republic of Germany]

This paper illustrates how German physiologists during the Second World War succeeded in making a case for the relevance of their research for the war effort. In this way the paper contributes to the recent historical debate about how scientists--in this case the physiologists--could enforce their interests within the National Socialist system and to what extent they were "misused" by the political and military leaders. Most scientists were able to continue their careers in the new political system after 1945, using the old scientific network from the National Socialist era. They successfully changed their research topics, responding quickly to the new challenges in peace. As a typical example the career of the physiologist Hans Schäfer is described in this article.

[Reorientation of German tropical medicine--research on smallpox vaccine in post-war Germany]

The German Research Foundation (Deutsche Forschungsgemeinschaft, DFG) supported a reorientation of research in tropical medicine after the Second World War, in the direction of virus research, by financing relevant research projects and the establishment of entire departments, or by guaranteeing the subsistence of institutes. During the post-war period research was focussed on the smallpox vaccine, especially because severe vaccine-induced side effects, such as post-vaccination encephalitis, attracted attention. Research on smallpox vaccination thus formed the backbone of German tropical medical research and its institutional basis, with the DFG providing the financial basis.

The history of Yunosawa village and the leprosy policy in Japan: a study of a free medical-treatment area for leprosy patients

The village of Yunosawa, near Kusatsu town, Gunma Prefecture, Japan, existed as a refuge for Hansen's disease sufferers from 1887 to 1941. It was the only such place to maintain, to its final closure, self-government free from the pre-war State isolation policy. The aim of this study is to clarify the dynamism from the notion of "the protection from social persecution of leprosy patients" to the notion of "the defense of society from the leprosy patients as a source of infection". Herein, I will explain history of Yunosawa village and its relation to the shift in State policy concerning leprosy. In addition, I will demonstrate the value of a free medical-treatment area.