Storylines of family medicine V: ways of thinking-honing the therapeutic self

Storylines of Family Medicine is a 12-part series of thematically linked essays with accompanying illustrations that explore the many dimensions of family medicine, as interpreted by individual family physicians and medical educators in the USA and elsewhere around the world. In 'V: ways of thinking-honing the therapeutic self', authors present the following sections: 'Reflective practice in action', 'The doctor as drug-Balint groups', 'Cultivating compassion', 'Towards a humanistic approach to doctoring', 'Intimacy in family medicine', 'The many faces of suffering', 'Transcending suffering' and 'The power of listening to stories.' May readers feel a deeper sense of their own therapeutic agency by reflecting on these essays.

Academic Health Centers and Humanitarian Crises: One Health System's Response to Unaccompanied Children at the Border

University of California Health (UCH) provided a system-wide, rapid response to the humanitarian crisis of unaccompanied children crossing the southern U.S. border in the midst of the COVID-19 pandemic in 2021. In collaboration with multiple federal, state, and local agencies, UCH mobilized a multidisciplinary team to deliver acute general and specialty pediatric care to unaccompanied children at 2 Californian emergency intake sites (EISs). The response, which did not disrupt normal UCH operations, mobilized the capacities of the system and resulted in a safe and developmentally appropriate environment that supported the physical and mental health of migrant children during this traumatic period. The capacities of UCH's 6 academic health centers ensured access to trauma-informed medical care and culturally sensitive psychological and social support. Child life professionals provided access to exercise, play, and entertainment. Overall, 260 physicians, 42 residents and fellows, 4 nurse practitioners participated as treating clinicians and were supported by hundreds of staff across the 2 EISs. Over 5 months and across both EISs, a total of 4,911 children aged 3 to 17 years were cared for. A total of 782 children had COVID-19, most infected before arrival. Most children (3,931) were reunified with family or sponsors. Continuity of care after reunification or placement in a long-term shelter was enhanced by use of an electronic health record. The effort provided an educational experience for residents and fellows with instruction in immigrant health and trauma-informed care. The effort benefitted from UCH's recent experience of providing a system-wide response to the COVID-19 pandemic. Lessons learned are reported to encourage the alignment and integration of academic health centers' capacities with federal, state, and local plans to better prepare for and respond to the accelerating need to care for those in the wake of disasters and humanitarian crises.

Views from the trenches: California family physicians' challenges and resilience factors while providing patient care during the initial wave of COVID-19

This study examined challenges and factors promoting resilience among 20 California family physicians (FPs) during the first six months of the COVID-19 pandemic. A subset of academic, community, and resident FPs who responded to an online survey also participated in a semi-structured interview that explored concerns, moral distress, burnout, resource needs, support systems, coping strategies, and motivation to continue caring for patients. Thematic analysis was used to identify common themes in participant interviews. Interviewees demonstrated adaptability, resilience, and grit (i.e., commitment to completing a valued goal in the face of setbacks and adversity) despite challenges disrupting patient care, fears for family and self, and frustration due to the politicization of the pandemic. Factors promoting well-being and perseverance included professional and personal support, strong coping skills, and focusing on the meaning derived from practicing medicine. A service orientation that permeates family medicine philosophy and values motivated practitioners to continue to provide patient care while dealing with overwhelming personal and structural challenges. FPs drew strength from their internal coping skills, core family medicine values, and external support, notwithstanding demoralizing effects of mixed messages and politicization of the pandemic. FPs demonstrated resilience and grit in the face of challenges created by the COVID-19 pandemic. Ensuring adequate resources to promote a physically and psychologically healthy workforce while increasing access to care for all patients is crucial to prepare for the next healthcare crisis.

Occupational health within the bounds of primary care: Factors shaping the health of Latina/o immigrant workers in federally qualified health centers

BACKGROUND

Many workers seek care for work-related medical conditions in primary care settings. Additionally, occupational medicine training is not consistently addressed in primary care professional training. These patterns raise concerns about the health outcomes of low-wage Latina/o immigrant workers who make use of primary care settings to obtain care for work-related injuries and illnesses. The objective of this qualitative study was to investigate how primary care clinicians assessed and addressed the role of occupational exposures on the health and well-being of Latina/o immigrant workers.

METHODS

We conducted semistructured in-depth interviews with 17 primary care clinicians (physicians, resident physicians, and nurse practitioners) employed in an urban federally qualified health center (FQHC) with two sites located in Orange County, CA.

RESULTS

Using a constructivist grounded theory approach, we determined that primary care clinicians had a general understanding that employment influenced the health and well-being of their Latina/o immigrant patients. Clinicians delivered care to Latina/o immigrant workers who feared reporting their injury to their employer and to Latina/o immigrants whose workers' compensation claim was terminated before making a full recovery. Clinicians were responsive to patients' work-related concerns and leveraged the resources available within the FQHC. Although some clinicians offered suggestions to improve occupational health in the FQHC, a few clinicians raised concerns about the feasibility of additional health screenings and clinic-based interventions, and pointed to the importance of interventions outside of the healthcare system.

CONCLUSION

This study underscores the complexities of addressing occupational health concerns in urban FQHCs.

Common Sleep Disorders in Children

Childhood sleep disorders can disrupt family dynamics and cause cognitive and behavior problems. Early recognition and management can prevent these complications. Behavior subtypes of childhood insomnias affect 10% to 30% of children and result from inconsistent parental limit-setting and improper sleep-onset association. Behavior insomnias are treated using extinction techniques and parent education. Hypnotic medications are not recommended. Obstructive sleep apnea affects 1% to 5% of children. Polysomnography is required to diagnose obstructive sleep apnea; history and physical examination alone are not adequate. Adenotonsillectomy is the first-line treatment for obstructive sleep apnea. Nasal continuous positive airway pressure is the second-line treatment for children who do not respond to surgery or if adenotonsillectomy is contraindicated. Restless legs syndrome can be difficult to recognize and has an association with attention-deficit/hyperactivity disorder. Management of restless legs syndrome includes treatment of iron deficiency, if identified, and removal of triggering factors. Parasomnias affect up to 50% of children and usually resolve spontaneously by adolescence. Management of parasomnias involves parental education, reassurance, safety precautions, and treating comorbid conditions. Delayed sleep phase syndrome is found during adolescence, manifesting as a night owl preference. Treatment of delayed sleep phase syndrome includes sleep hygiene, nighttime melatonin, and morning bright light exposure. Sleep deprivation is of increasing concern, affecting 68% of people in high school.

Immigrant Health and Changes to the Public-Charge Rule: Family Physicians' Response

As the US federal government pursues immigration reform, changes to the federal public-charge rule have triggered confusion and concerns among patients who are immigrants. Although federal judges temporarily blocked implementation, a decision by the Supreme Court in January 2020 allowed the proposed changes to take effect. These policy changes have resulted in many legal immigrants and their family members becoming more reluctant to apply for health insurance, food, housing, and other benefits for which they are qualified. This article summarizes the changes and exclusions. Family physicians can effectively respond to patient and immigrant community concerns about these changes by providing outreach education, access to primary health care, and referrals to legal and social services.

Roles and challenges of family physicians in Uganda: A qualitative study

BACKGROUND

The World Health report (2008), the World Health Assembly (2009) and the Declaration of Astana (2018) acknowledge the significant contribution of family physicians (FPs) in clinical and primary healthcare. Given the lack of resources and low numbers of FPs coupled with the contextual nature of family medicine (FM), the scope of practice of African FPs is likely to differ from that of colleagues in America and Europe. Thus, this study explored the roles of Ugandan FPs and the challenges they face.

METHODS

This cross-sectional qualitative study was conducted through in-depth interviews with FPs who are working in Uganda. Participants who work in public and private healthcare systems including non-governmental organisations and in all geographical regions were purposively selected. Interviews were conducted from July 2016 to June 2017. Qualitative thematic content analysis of the transcripts was performed using a framework approach.

RESULTS

The study team identified three and six thematic roles and challenges, respectively, from the interview transcripts. The roles were clinician, leadership and teaching and learning. Challenges included lack of common identity, low numbers of FPs, conflicting roles, unrealistic expectations, poor organisational infrastructure and lack of incentives.

CONCLUSION

The major roles of FPs in Uganda are similar to those of their counterparts in other parts of the world. Family physicians provide clinical care for patients, including preventive and curative services; providing leadership, management and mentorship to clinical teams; and teaching and learning. However, their roles are exercised differently as a result of lack of proper institutionalisation of FM within the Uganda health system. Family physicians in Uganda have found many opportunities to contribute to healthcare leadership, education and service, but have not yet found a stable niche within the healthcare system.

Time for action: key considerations for implementing social accountability in the education of health professionals

Within health professional education around the world, there exists a growing awareness of the professional duty to be socially responsible, being attentive to the needs of all members of communities, regions, and nations, especially those who disproportionately suffer from the adverse influence of social determinants. However, much work still remains to progress beyond such good intentions. Moving from contemplation to action means embracing social accountability as a key guiding principle for change. Social accountability means that health institutions attend to improving the performance of individual practitioners and health systems by directing educational and practice interventions to promote the health of all the public and assessing the systemic effects of these interventions. In this Reflection, the authors (1) review the reasons why health professional schools and their governing bodies should codify, in both curricular and accreditation standards, norms of excellence in social accountability, (2) present four considerations crucial to successfully implementing this codification, and (3) discuss the challenges such changes might entail. The authors conclude by noting that in adopting socially accountable criteria, schools will need to expand their philosophical scope to recognize social accountability as a vitally important part of their institutional professional identity.

Continuity and Access in the Era of Part-Time Practice

The number of physicians seeing patients part time is growing, an evolution that challenges the primary care pillars of continuity and access. The growth of part-time practice is a response to burnout and to the pressures facing primary care physicians. Physicians who work fewer clinical hours and thereby reduce burnout are more satisfied with their careers, less likely to leave their jobs, and provide a better patient experience. Primary care practices can make a number of adjustments to optimize continuity and access in this era of part-time practice. Moreover, physicians who work fewer clinical hours are equally capable of fostering trusting relationships with patients as physicians seeing patients full time.

Perspectives of female medical faculty in Ethiopia on a leadership fellowship program

OBJECTIVES

This study aims to evaluate a leadership fellowship program through perspectives of Ethiopian women medical faculty participants.

METHODS

An intensive two-week leadership development fellowship was designed for women faculty from Ethiopian medical schools and conducted from 2011-2015 at the University of Wisconsin-School of Medicine and Public Health in Madison, Wisconsin. Nine Ethiopian women working in early- or mid-level academic positions were selected. Semi-structured interviews were conducted with the fellows. Transcripts were reviewed through qualitative analysis to assess the perceived impact of the training on their careers. Three male academic leaders were interviewed to solicit feedback on the program.

RESULTS

Eight of 9 fellows were interviewed. Themes describing the benefits of the fellowship included: increased awareness of gender inequities; enhanced motivation for career advancement; increased personal confidence; and improved leadership skills. Fellows provided suggestions for future training and scaling up efforts to promote gender equity. Male leaders described the benefits of men promoting gender equity within academic health centers.

CONCLUSIONS

This paper provides evidence that targeted brief training programs can enhance women's motivation and skills to become effective leaders in academic medicine in Ethiopia. Promoting gender equity in academic medicine is an important strategy to address health workforce shortages and to provide professional role models for female students in the health professions.

Developing family practice to respond to global health challenges: The Besrour Papers: a series on the state of family medicine in the world

OBJECTIVE

To assess family medicine's role in developing strong, coordinated, community-based, integrated health care systems in low-resource settings globally.

COMPOSITION OF THE COMMITTEE

A subgroup of the Besrour Centre of the College of Family Physicians of Canada developed connections with selected international colleagues with expertise in international family medicine practice, health systems and capacity building, and teaching to map family medicine globally and give a bird's eye view of family medicine internationally.

METHODS

Following a background literature review, the authors collectively reflected on their substantial international experience to attempt to describe best practices for various contexts.

REPORT

With the failure of vertical, disease-oriented models to provide sustained improvements in health outcomes, the need to develop integrated primary care involving the most appropriate health professionals for differing contexts is becoming apparent worldwide. Health system planning is required to develop policies on health professional training to achieve this. Advocating and offering appropriate incentives for, and coordination of, local opportunities within the health system also becomes paramount. The adaptability and generalist nature of family medicine allows it to respond to the unique needs of a given population. Family physicians with adequate financial and physical resources can function most effectively as members of interdisciplinary teams, thus providing valuable, comprehensive health services in any area of the world.

¡Venga Y Relájese! Pilot Stress Reduction Program for Migrant Latina Women Living in Low-Resource Settings From Milwaukee to Lima

Latina women living in low-income communities frequently report a high prevalence of feeling physically and/or emotionally "unwell." Formative focus groups were used to design a 3-session stress reduction curriculum called ¡Venga y Relájese! (Come and relax yourself!). Survey data from 5 Milwaukee cohorts and 1 Peruvian cohort revealed statistically significant improvements in general health status, perceived stress status, and confidence to manage future stress among women who completed all sessions (n=54). The pilot ¡Venga y Relájese! stress reduction curriculum yielded benefits for Latina women living in low-income neighborhoods in Milwaukee, Wisconsin and Lima, Peru.

Family medicine around the world: overview by region: The Besrour Papers: a series on the state of family medicine in the world

OBJECTIVE

To demonstrate how family medicine has been recognized and integrated into primary health care systems in contrasting contexts around the world and to provide an overview of how family physicians are trained and certified.

COMPOSITION OF THE COMMITTEE

Since 2012, the College of Family Physicians of Canada has hosted the Besrour Conferences to reflect on its role in advancing the discipline of family medicine globally. The Besrour Papers Working Group, which was struck at the 2013 conference, was tasked with developing a series of papers to highlight the key issues, lessons learned, and outcomes emerging from the various activities of the Besrour collaboration. The working group comprised members of various academic departments of family medicine in Canada and abroad who attended the conferences.

METHODS

An initial search was conducted in PubMed using a family medicine hedge of MeSH terms, text words, and family medicine journals, combined with text words and terms representing low- and middle-income countries and the concept of family medicine training programs. A second search was completed using only family medicine terms in the CAB Direct and World Bank databases. Subsequent PubMed searches were conducted to identify articles about specific conditions or services based on suggestions from the authors of the articles selected from the second search. Additional articles were identified through reference lists of key articles and through Google searches. We then attempted to verify and augment the information through colleagues and partners.

REPORT

The scope of family medicine and the nature of family medicine training vary considerably worldwide. Challenges include limited capacity, incomplete understanding of roles, and variability of standards and recognition. Opportunities for advancement might include technology, collaboration, changes in pedagogy, flexible training methods, and system-wide support.

Family Medicine Global Health Fellowship Competencies: A Modified Delphi Study

BACKGROUND AND OBJECTIVES

Many US medical schools and family medicine departments have responded to a growing interest in global health by developing global health fellowships. However, there are no guidelines or consensus statements outlining competencies for global health fellows. Our objective was to develop a mission and core competencies for Family Medicine Global Health Fellowships.

METHODS

A modified Delphi technique was used to develop consensus on fellowship competencies. A panel, comprised of 13 members with dual expertise in global health and medical education, undertook an iterative consensus process, followed by peer review, from April to December 2014.

RESULTS

The panel developed a mission statement and identified six domains for family medicine global health fellowships: patient care, medical knowledge, professionalism, communication and leadership, teaching, and scholarship. Each domain includes a set of core and program-specific competencies.

CONCLUSION

The family medicine global health competencies are intended to serve as an educational framework for the design, implementation, and evaluation of individual family medicine global health fellowship programs.

Training in Urban Medicine and Public Health: Preparing Physicians to Address Urban Health Care Needs

BACKGROUND

Wisconsin is facing significant physician shortages. The University of Wisconsin School of Medicine and Public Health (UWSMPH) launched Training in Urban Medicine and Public Health (TRIUMPH) to recruit and prepare medical students to serve people living within urban Health Professional Shortage Areas.

METHODS

Students are selected based on their commitment to improve health equity for urban populations. They complete clinical rotations, core curriculum, and community projects in Milwaukee, Wisconsin.

RESULTS

Full program graduates are more likely to match into residencies serving the urban poor (50/50, 100%) and pursue primary care specialties (40/50, 80.0%) compared to nonprogram graduates.

DISCUSSION

The TRIUMPH program has been successful in its mission to encourage graduates to serve urban communities. The authors discuss urban health disparities, TRIUMPH outcomes, and the need for similar programs.

PROMOTING GENDER EQUITY AT THE COLLEGE OF HEALTH SCIENCES, ADDIS ABABA UNIVERSITY, ETHIOPIA

BACKGROUND

Ethiopia faces a dire shortage of human resources to meet the health care needs of its population of more than 90 million people. The government has implemented programs to expand the health care workforce, of which women are a growing and crucial component. Universities are working to identify and address gender inequity to help recruit and retain women.

OBJECTIVE

This paper describes and analyzes a multi-institution grant-funded program to promote gender equity at Addis Ababa University-College of Health Sciences (AAU-CHS) in Ethiopia.

METHODS

The primary intervention was to provide intensive short-term fellowships to mid-level female faculty to facilitate their promotion into leadership positions. Secondary interventions included a series of gender equity meetings with students, residents and staff to elicit bottom-up concerns and recommendations for future action, as well as conducting a gender climate survey of female students and staff External consultants assisted with program implementation, monitoring and evaluation of the program.

RESULTS

Initial outcomes demonstrate promising career advancement of women who participated in the fellowships. A comprehensive gender equity action plan was developed based upon results from the survey and meeting recommendations. This plan is being implemented by AAU-CHS faculty and administration.

CONCLUSION

This program has been an initial success and may serve as a template for others who are working to promote gender equity.

Creating a Culture of Mindfulness in Medicine

BACKGROUND

Well-documented challenges faced by primary care clinicians have brought growing awareness to the issues of physician wellness and burnout and the potential subsequent impact on patients. Research has identified mindfulness as a tool to increase clinician well-being and enhance clinician characteristics associated with a more patient-centered orientation to clinical care.

OBJECTIVE

The overall goal of our intervention was to promote the cultivation of mindful awareness throughout our health system, creating a culture of mindfulness in medicine.

METHODS

We developed a systems-level strategy to promote health and resilience for clinicians and patients by preparing a group of clinician leaders to serve as catalysts to practice and teach mindfulness. The strategy involved 3 steps: (1) select 5 primary care leaders to help foster mindfulness within both health care delivery and education; (2) provide funds for these leaders to attend advanced mindfulness training designed specifically for clinicians; and (3) foster mindfulness within our health system and beyond via collaborative planning meetings and seed money for implementation of projects.

RESULTS

All 5 leaders endorsed the personal value of the mindfulness training, with some describing it as life-changing. Within 8 months, 4 of the leaders fostered a wide variety of mindfulness activities benefitting colleagues, medical students, and patients across our state and beyond.

CONCLUSION

We found that the value received from our investment in mindfulness far exceeded our relatively low cost, although further evaluation is needed to prove this.

The dawn of family medicine in Ethiopia

This article describes the development of the first training program in family medicine in Ethiopia that was launched on February 4, 2013, at Addis Ababa University (AAU). The postgraduate program will prepare highly trained doctors for all parts of the country who choose generalism for their lifelong career. The paper describes a series of strategies that were used from 2008 to 2013 to take the Ethiopian family medicine program from vision to reality. There is no single model for the development of family medicine in a country where it does not yet exist. In this case the strategies included Continuing Medical Education events, discussions with stakeholders, international collaboration, needs assessment, curriculum design, and faculty development. The article also reviews both the potential for a new program in family medicine to contribute to the country's health system plus the challenges that are expected in the early stages of establishing a new specialty. The challenges include the ambiguous roles of the family physician in the Ethiopian health care system, uncertainty about career opportunities, adaptation of the curriculum to address local needs, expansion of the training programs to produce larger numbers of family physicians, development of Ethiopian faculty who will be teachers of family medicine, and internal and external brain drain. Family physicians will need to maintain a respectful relationship with other specialist physicians as well as nonphysician primary care providers. The development of this AAU family medicine residency is an example of a successful inter- institutional relationship between local and international partners to create a sustainable, Ethiopian-led training program. Insights from this article may guide development of similar training programs.

Toward a cultural consciousness of self in relationship: from "us and them" to "we"

While skills and techniques can help family physicians and other health professionals achieve basic competence in working across cultural and social boundaries, perhaps their most important tasks are those directed inward toward attitudes, beliefs, and capacities for self-exploration. This essay links the practice and teaching of cross-cultural medicine to clinicians' and educators' exploration of their own self- consciousness. The more they are willing to explore the unfamiliar within themselves, the more emotionally and psychologically comfortable they can become in dealing with the joys and challenges inherent in cross-cultural medicine. Several practices can foster this development of a sense of self in relationship with others. As health professionals and medical educators recognize and promote an awareness of self in relationship, they can enhance their personal and professional roles to become more effective advocates of equity and social justice in every clinical encounter.

Training in Urban Medicine and Public Health: TRIUMPH

PURPOSE

The number of U.S. medical school graduates who choose to practice in health professional shortage areas (HPSAs) has not kept pace with the needs of society. The University of Wisconsin School of Medicine and Public Health has created a new program that prepares medical students to reduce health disparities for urban medically underserved populations in Milwaukee. The authors describe the Training in Urban Medicine and Public Health (TRIUMPH) program and provide early, short-term outcomes.

METHOD

TRIUMPH integrates urban clinical training, community and public health curricula, longitudinal community and public health projects, mentoring, and peer support for select third- and fourth-year medical students. The authors tracked and held focus groups with program participants to assess their knowledge, skills, satisfaction, confidence, and residency matches. The authors surveyed community partners to assess their satisfaction with students and the program.

RESULTS

From 2009 to 2012, 53 students enrolled in the program, and 45 have conducted projects with community organizations. Participants increased their knowledge, skills, confidence, and commitment to work with urban medically underserved populations. Compared with local peers, TRIUMPH graduates were more likely to select primary care specialties and residency programs serving urban underserved populations. Community leaders have reported high levels of satisfaction and benefits; their interest in hosting students exceeds program capacity.

CONCLUSIONS

Early, short-term outcomes confirm that TRIUMPH is achieving its desired goals: attracting and preparing medical students to work with urban underserved communities. The program serves as a model to prepare physicians to meet the needs of urban HPSAs.

Creating a center for global health at the University of Wisconsin-Madison

Globalization, migration, and widespread health disparities call for interdisciplinary approaches to improve health care at home and abroad. Health professions students are pursuing study abroad in increasing numbers, and universities are responding with programs to address these needs. The University of Wisconsin (UW)-Madison schools of medicine and public health, nursing, pharmacy, veterinary medicine, and the division of international studies have created an interdisciplinary center for global health (CGH). The CGH provides health professions and graduate students with courses, field experiences, and a new Certificate in Global Health. Educational programs have catalyzed a network of enthusiastic UW global health scholars. Partnerships with colleagues in less economically developed countries provide the foundation for education, research, and service programs. Participants have collaborated to improve the education of health professionals and nutrition in Uganda; explore the interplay between culture, community development, and health in Ecuador; improve animal health and address domestic violence in Mexico; and examine successful public health efforts in Thailand. These programs supply students with opportunities to understand the complex determinants of health and structure of health systems, develop adaptability and cross-cultural communication skills, experience learning and working in interdisciplinary teams, and promote equity and reduce health disparities at home and abroad. Based on the principles of equity, sustainability, and reciprocity, the CGH provides a strong foundation to address global health challenges through networking and collaboration among students, staff, and faculty within the UW and beyond.

Strengthening Primary Health Care with Family and Community Medicine in Brazil

This paper reviews the development of the specialty of family medicine with attention to strategies that may be used to strengthen Brazilian health care with appropriately trained family doctors. These strategies include establishing academic departments of family and community medicine in all Brazilian medical schools, ensuring a common core curriculum in training programs, and defining standards for the evaluation and certification of family doctors. These strategies could enhance the quality, scope and effectiveness of the Brazilian Family Healthcare Program.

Career influence of an international health experience during medical school

BACKGROUND AND OBJECTIVES

International health (IH) experiences are popular among medical students and may influence career choices. The International Health Fellowship Program (IHFP) consisted of preparatory coursework and field experience in a developing country. We conducted a survey 4-7 years later to assess the career influence of IHFP participation.

METHODS

Fellows completed a questionnaire regarding training, practice setting, patient population, further international work, and knowledge and attitudes about IH.

RESULTS

Surveys were completed by 42 (70%) fellows; 31% spend most of their time working with underserved populations, 67% have been involved in community health projects, 74% practice primary care, 29% have an MPH degree, 57% have done further work in developing countries, while 90% named one or more barriers to further IH experiences. Knowledge and attitudes about IH were largely retained. Most fellows (67%) believed the IHFP influenced their careers.

CONCLUSIONS

Most fellows felt that IHFP participation had a positive influence on their careers. While a causative relationship cannot be inferred, fellows demonstrate a strong preference to work with underserved populations and engage in community service activities. Compared with US physicians, IHFP fellows are more likely to practice primary care and obtain MPH degrees. Medical schools that seek to produce graduates with these qualities should make efforts to increase quality IH opportunities for their students.

Integrating the art and science of medical practice: innovations in teaching medical communication skills

BACKGROUND AND OBJECTIVES

This paper describes the content and methods used to teach communication skills in Undergraduate Medical Education for the 21st Century (UME-21) schools and provides suggestions for future efforts.

METHODS

Faculty leaders of curriculum projects at UME-21 schools provided reports describing new communication curriculum projects. Reports were reviewed and analyzed, curriculum content and methods were categorized into themes, and findings were confirmed through phone interviews with lead faculty at each participating school.

RESULTS

Curriculum projects were designed to improve medical students' communication skills during the clerkship years at 12 participating UME-21 schools. These skills were addressed through a variety of teaching methods and applied in interactions with patients, health teams, and community members. Curricular themes included conflict resolution, delivery of bad news, addressing patient preferences for end-of-life care, patient and community health education, communicating with families, and working effectively with patients from diverse backgrounds. Students' communication skill competencies were assessed through a variety of methods including objective structured clinical examinations, focused observation and feedback, and debriefing sessions based on recall, audiotapes, or videotapes of encounters.

CONCLUSIONS

Opportunities for students to develop, apply, and refine their communication skills can be embedded throughout the medical school curricula. Our findings illustrate the variety of methods that may be used to teach and evaluate medical students' communication skill competencies. Future challenges include development of comprehensive longitudinal curricula, practical teaching methods, valid evaluation tools, and faculty development.

Leadership Opportunities with Communities, the Medically Underserved, and Special Populations (LOCUS)

OBJECTIVES

The Leadership Opportunities with Communities, the Underserved, and Special Populations (LOCUS) Program aims to improve medical students' leadership knowledge and skills, to improve self-awareness and motivation for community service, and to provide models for students to integrate community service into their medical careers.

DESCRIPTION

The LOCUS program was established as a longitudinal, extracurricular student opportunity at the University of Wisconsin Medical School in the fall of 1998. Up to 15 new students each year are selected for the program through an application and interview process during their first or second year of medical school. Students remain in the program from acceptance until graduation from medical school. Nearly 50 students have enrolled in the program to date. LOCUS fellows are matched with a physician mentor, participate in core curriculum activities, and complete a longitudinal community service project. Mentors are community generalist physicians who have integrated community service into their own careers. Students participate in their mentors' clinical practices one afternoon a month during the first two years, and mentors serve as role models and provide guidance for students' projects and career development. The program administration and staff are supported through federal predoctoral training and Area Health Education Centers (AHEC) grants. The LOCUS core curriculum is delivered through a series of retreats, workshops, and seminars that emphasize active learning methods and include approximately 20 hours of scheduled activities per academic year. The curriculum addresses concepts of leadership in relation to one's self and in relation to others. Students are introduced to methods of self-reflection and develop their own vision and mission statements. Students also discuss the importance of compassion, self-care, striving for balance, avoiding burnout, and being realistic about what they can accomplish. Students practice strategies for working with teams, organizing meetings, working with media, taking political action, and resolving conflicts. They acquire community health skills such as assessing the health needs of a defined population; engaging community members' participation in health program development; and selecting priorities, designing interventions, and measuring the progress of community health care. Working in small teams, LOCUS fellows apply and refine their leadership skills through design and completion of a community health service project. Students can design their own projects or work on projects designed by community partners. The projects have addressed a variety of community health needs, such as parenting support for teen mothers, teaching health education for residents of group homes, and providing free sports physical exams for uninsured youth.

DISCUSSION

This pilot program demonstrates that motivated students can develop leadership skills and address unmet community health needs while they progress through medical school. LOCUS students, staff, and physicians provide a social network that includes opportunities, encouragement, reflection, and problem solving. Student and mentor satisfaction with the program has been high. Future challenges include securing long-term funding, refining the core curriculum, assessing the impact of the program on participants, and improving the quality of projects through community partnerships. LOCUS strives to kindle the fires of altruism and community service so they are not extinguished as students progress through medical training.

Factors influencing rural Wisconsin elders in completing advance directives

PURPOSE

Advance directives can assist in end-of-life decision-making. This study explores the factors that influence completion of advance directives.

METHODS

Qualitative study using in-depth interviews of 10 patients over age 60 in a rural office practice.

RESULTS

Major themes: (1) patient autonomy: the patient and family role as decision maker, the physician as educator; (2) barriers that deter patients from completing advance directives include fear and confusion about these documents; and (3) quality of life is an important value in end-of-life decision-making.

CONCLUSIONS

Decision making about advance directives is a personal and family issue, but physician efforts to initiate the process and educate patients are important, especially if done routinely in the office or preferably in community settings. The main difference between those who do and don't complete advance directives is an understanding of the documents and their purpose.

New world views: preparing physicians in training for global health work

BACKGROUND AND OBJECTIVES

To determine the impact of international health experiences on physicians in training, we studied 60 US medical students who participated in an International Health Fellowship Program (IHFP).

METHODS

In 1995 and 1996, US medical students were selected to participate in the IHFP, which included training at three US medical schools and at seven medical schools in developing countries. The program included a 2-week preparatory course at a US school and a 6- to 8-week field experience. Evaluative data were collected prior to the course, after the course, after the field experience, and 1-2 years later.

RESULTS

A total of 60 students were selected from 145 applicants. At the end of the fellowship, a majority of participants noted that the exposure affected them in the following ways: changed world views; increased cultural sensitivity; enhanced community, social, and public health awareness; enhanced clinical and communication skills; more appropriate resource utilization; changes in career plans; and a greater understanding of the challenges of working in areas with scarce resources. After the international field experience, students more strongly agreed with the importance of oral rehydration, communication skills, and patient education. According to student self-assessments, the IHFP significantly improved core medical skills. Ninety-six percent of participants recommended international health experiences for other students.

CONCLUSIONS

This study of IHFP fellows demonstrates multiple significant impacts of international health experiences on US medical students in training. The knowledge, attitudes, and skills gained through international health experiences are important for medical practice in the United States and abroad. Given the high interest of medical students in international health and the potential for positive educational impacts, medical schools should increase the availability of high-quality international experiences.

Integrating prevention education into the medical school curriculum: the role of departments of family medicine

Departments of family medicine--including departments of family and community medicine, departments of family and preventive medicine, and departments of family practice-at U.S. medical schools regularly participate in teaching prevention principles to students, using a variety of formats and methods. Required clinical experiences (i.e., clerkships and preceptorships), required nonclinical courses, and electives frequently include prevention content. Collaborative interdisciplinary clerkships, interdisciplinary nonclinical courses, and courses directed by other departments also enable family medicine faculty to teach prevention principles. This article describes examples of innovative educational programs in which family medicine faculty teach prevention content to medical students. Directions for future educational efforts by family medicine faculty in the prevention area are proposed.

Precepting preclinical students

Preclinical preceptors have an opportunity to imprint students with good clinical work habits, professionalism, and excitement for medical education. While attention to the multiple roles of the preclinical preceptor can add responsibilities to a busy physician's day, the chance to influence the development of future physicians is deeply gratifying.

Where there is no family doctor: the development of family practice around the world

Family physicians are generalists trained at the postgraduate level to address the majority of primary care needs of patients of all ages in communities they serve. Throughout the world there is a need for family physicians to serve as cornerstones of comprehensive health care systems that provide high-quality, cost-effective medical and public health services to the entire population. To meet this need, each country must value and adequately finance essential medical and public health services and must provide family physicians with a thorough education focused on the relevant health care problems of the population being served. The authors present an overview of the status of this training throughout the world, outline challenges to the development of such training, and suggest strategies for successful development accompanied by illustrative case studies from South Korea, Venezuela, and Pakistan.