Primary Care Training and the Evolving Healthcare System

The Community Primary Care Champions Fellowship: a mixed methods evaluation of an interprofessional fellowship for physician assistants and physicians

BACKGROUND

Primary care in the US faces challenges with clinician recruitment, retention, and burnout, with further workforce shortages predicted in the next decade. Team-based care can be protective against clinician burnout, and opportunities for interprofessional education (IPE) on professional development and leadership could encourage primary care transformation. Despite an increasingly important role in the primary care workforce, IPE initiatives training physician assistants (PAs) alongside physicians are rare. We describe the design, curriculum, and outcomes from an interprofessional primary care transformation fellowship for community-based primary care physicians and PAs.

METHODS

The Community Primary Care Champions (CPCC) Fellowship was a one-year, part-time fellowship which trained nine PAs, fourteen physicians, and a behavioralist with at least two years of post-graduate clinical experience in six content pillars: quality improvement (QI), wellness and burnout, mental health, social determinants of health, medical education, and substance use disorders. The fellowship included a recurring schedule of monthly activities in self-study, lectures, mentoring, and community expert evening discussions. Evaluation of the fellowship included pre, post, and one-year follow-up self-assessments of knowledge, attitudes, and confidence in the six content areas, pre- and post- wellness surveys, lecture and discussion evaluations, and midpoint and exit focus groups.

RESULTS

Fellows showed significant improvement in 24 of 28 self-assessment items across all content areas post-fellowship, and in 16 of 18 items one-year post-fellowship. They demonstrated reductions in emotional exhaustion and depersonalization post-fellowship and increased confidence in working in interprofessional teams post-fellowship which persisted on one-year follow-up assessments. All fellows completed QI projects and four presented their work at national conferences. Focus group data showed that fellows experienced collaborative, meaningful professional development that was relevant to their clinical work. They appreciated the flexible format and inclusion of interprofessional community experts in evening discussions.

CONCLUSIONS

The CPCC fellowship fostered an interprofessional community of practice that provided an effective IPE experience for physicians and PAs. The learning activities, and particularly the community expert discussions, allowed for a flexible, relevant experience, resulting in personal and professional growth along with increased confidence working within interprofessional teams.

Practical Opportunities for Biopsychosocial Education Through Strategic Interprofessional Experiences in Integrated Primary Care

Even with the expansion of primary care teams to include behavioral health and other providers from a range of disciplines, providers are regularly challenged to deliver care that adequately addresses the complex array of biopsychosocial factors underlying the patient's presenting concern. The limits of expertise, the ever-changing shifts in evidence-based practices, and the difficulties of interprofessional teamwork contribute to the challenge. In this article, we discuss the opportunity to leverage the interprofessional team-based care activities within integrated primary care settings as interactive educational opportunities to build competencies in biopsychosocial care among primary care team members. We argue that this approach to learning while providing direct patient care not only facilitates new provider knowledge and skills, but also provides a venue to enhance team processes that are key to delivering integrated biopsychosocial care to patients. We provide three case examples of how to utilize strategic planning within specific team-based care activities common in integrated primary care settings-shared medical appointments, conjoint appointments, and team huddles-to facilitate educational objectives.

Meeting the demand of the future: a curriculum to stimulate interest in careers in primary care internal medicine

BACKGROUND

There is a growing need for primary care physicians, but only a small percentage of graduating medical students enter careers in primary care.

PURPOSE

To assess whether a Primary Care Intraclerkship within the Medicine clerkship can significantly improve students' attitudes by analyzing scores on pre- and post-tests.

METHODS

Students on the Medicine clerkship at the University of Massachusetts Medical School participated in full-day 'intraclerkships',to demonstrate the importance of primary care and the management of chronic illness in various primary care settings. Pre-and post-tests containing students' self-reported, five-point Likert agreement scale evaluations to 26 items (measuring perceptions about the roles of primary care physicians in patient care and treatment) were collected before and after each session. Eleven intraclerkships with 383 students were held between June 2010 and June 2013. Responses were analyzed using the GLM Model Estimate.

RESULTS

Results from the survey analysis showed significantly more positive attitudes toward primary care in the post-tests compared to the pre-tests. Students who were satisfied with their primary care physicians were significantly more likely to show an improvement in post-test attitudes toward primary care in the areas of physicians improving the quality of patient care, making a difference in overall patient health, finding primary care as an intellectually challenging field, and in needing to collaborate with specialists. Older students were more likely than younger students to show more favorable answers on questions concerning the relative value of primary care vs. specialty care.

CONCLUSIONS

A curriculum in Primary Care Internal Medicine can provide a framework to positively influence students' attitudes toward the importance of primary care, and potentially to influence career decisions to enter careers in Primary Care Internal Medicine. Ensuring that medical students receive excellent primary care for themselves can also positively influence attitudes toward primary care.

Is Training in a Primary Care Internal Medicine Residency Associated with a Career in Primary Care Medicine?

PURPOSE

Professional and governmental organizations recommend an ideal US physician workforce composed of at least 40 % primary care physicians. They also support primary care residencies to promote careers in primary care. Our study examines the relationship between graduation from a primary care or categorical internal medicine residency program and subsequent career choice.

METHODS

We conducted a cross-sectional electronic survey of a cohort of internal medicine residency alumni who graduated between 2001 and 2010 from a large academic center. Our primary predictor was graduation from a primary care versus a categorical internal medicine program and our primary outcome is current career role. We performed chi-square analysis comparing responses of primary care and categorical residents.

RESULTS

We contacted 481 out of 513 alumni, of whom 322 responded (67 %). We compared 106 responses from primary care alumni to 169 responses from categorical alumni. Fifty-four percent of primary care alumni agreed that the majority of their current clinical work is in outpatient primary care vs. 20 % of categorical alumni (p < 0.001). While 92.5 % of primary-care alumni were interested in a primary care career prior to residency, only 63 % remained interested after residency. Thirty of the 34 primary care alumni (88 %) who lost interest in a primary care career during residency agreed that their ambulatory experience during residency influenced their subsequent career choice.

CONCLUSIONS

A higher percentage of primary care alumni practice outpatient primary care as compared to categorical alumni. Some alumni lost interest in primary care during residency. The outpatient clinic experience may impact interest in primary care.

Utilizing a Meals on Wheels program to teach falls risk assessment to medical students

Falls are a critical public health issue for older adults, and falls risk assessment is an expected competency for medical students. The aim of this study was to design an innovative method to teach falls risk assessment using community-based resources and limited geriatrics faculty. The authors developed a Fall Prevention Program through a partnership with Meals-on-Wheels (MOW). A 3rd-year medical student accompanies a MOW client services associate to a client's home and performs a falls risk assessment including history of falls, fear of falling, medication review, visual acuity, a Get Up and Go test, a Mini-Cog, and a home safety evaluation, reviewed in a small group session with a faculty member. During the 2010 academic year, 110 students completed the in-home falls risk assessment, rating it highly. One year later, 63 students voluntarily completed a retrospective pre/postsurvey, and the proportion of students reporting moderate to very high confidence in performing falls risk assessments increased from 30.6% to 87.3% (p < .001). Students also reported using most of the skills learned in subsequent clerkships. A single educational intervention in the MOW program effectively addressed geriatrics competencies with minimal faculty effort and could be adopted by many medical schools.

Benefits and barriers among volunteer teaching faculty: comparison between those who precept and those who do not in the core pediatrics clerkship

BACKGROUND

Community-based outpatient experiences are a core component of the clinical years in medical school. Central to the success of this experience is the recruitment and retention of volunteer faculty from the community. Prior studies have identified reasons why some preceptors volunteer their time however, there is a paucity of data comparing those who volunteer from those who do not.

METHODS

A survey was developed following a review of previous studies addressing perceptions of community-based preceptors. A non-parametric, Mann-Whitney U test was used to compare active preceptors (APs) and inactive preceptors (IPs) and all data were analyzed in SPSS 20.0.

RESULTS

There was a 28% response rate. Preceptors showed similar demographic characteristics, valued intrinsic over extrinsic benefits, and appreciated Continuing Medical Education (CME)/Maintenance of Certification (MOC) opportunities as the highest extrinsic reward. APs were more likely to also precept at the M1/M2 level and value recognition and faculty development opportunities (p<0.05). IPs denoted time as the most significant barrier and, in comparison to APs, rated financial compensation as more important (p<0.05).

CONCLUSIONS

Community preceptors are motivated by intrinsic benefits of teaching. Efforts to recruit should initially focus on promoting awareness of teaching opportunities and offering CME/MOC opportunities. Increasing the pool of preceptors may require financial compensation.