Central Journal of Family Medicine & Community Health

Cite this article: Graddy R, Christmas C (2017) The Sparse Evidence Base for Primary Care Initiatives in U.S. Medical Schools. J Family Med Community Health 4(7): 1131.

Abstract

Introduction: In order to help meet the projected shortfall in primary care physician supply, over two thirds of medical schools in the United States have or soon will have initiatives to promote the primary care interest and skills of their students; however, the best practices to do so are not known.

Materials and methods: We conducted a comprehensive evaluation of peer-reviewed published literature from 2005-15 to determine best current practices in promoting primary care interest and skill in undergraduate medical education (UME).We identified themes among the outcomes described and rated the quality of the studies using the MERSQI score.

Results: 18 papers describing 16 distinct interventions were identified and abstracted by the authors. The quality of published outcomes varied substantially, with newer studies generally reporting higher quality results. Thematic analysis revealed that attention to location and educational format/duration were key to understanding this literature. Longer interventions and those deliberately focused on urban or rural education are more likely to be associated with post-graduation primary care practice in the target settings.

Conclusions: Despite the popularity of new educational initiatives to promote interest and skills in primary care in U.S. medical schools, evidence of effectiveness is limited. Recent increases in the number and quality of published UME primary care interventions are promising developments that will inform efforts to build and improve new programs. Available data suggests that longitudinal rural or urban-focused experiences may be particularly successful and deserve particular attention.

*Corresponding authorRyan Graddy, Department of Medicine, Johns Hopkins Bayview Medical Center, 5200 Eastern Ave., Baltimore, MD 21224, USA, Tel: 1-4105501943/8583422630; Fax: 1-4103672442; Email:

Submitted: 30 June 2017

Accepted: 12 September 2017

Published: 14 September 2017

ISSN: 2379-0547

Copyright© 2017 Graddy et al.

OPEN ACCESS

Keywords•Primary care•Uundergraduate medical education•Rural medicine

Short Communication

The Sparse Evidence Base for Primary Care Initiatives in U.S. Medical SchoolsRyan Graddy* and Colleen ChristmasDepartment of Medicine, Johns Hopkins University School of Medicine, USA

ABBREVIATIONSUME: Undergraduate Medical Education; MERSQI: Medical

Education Research Quality Instrument; LIC: Longitudinal integrated clerkship; USMLE: United States Medical Licensing Examination

INTRODUCTIONU.S. primary care has been widely recognized as “the

backbone of the nation’s health care system” [1] in an aging and increasingly medically complex society. Primary care doctors play key roles in providing and coordinating comprehensive, longitudinal prevention and treatment efforts at low cost, and in advocating for patients [2-6].

Medical school has traditionally included limited exposure to ambulatory medicine, and even less to longitudinal primary care experiences. Over the past several decades medical student interest in primary care fields has declined [7,8].

Educational institutions play an important role in trying to avert the impending national crisis in primary care; however, the

characteristics that render initiatives most likely to be successful in producing primary care-bound graduates are unclear. In this comprehensive literature review we sought to evaluate the quality of evidence detailing UME primary care programs in the U.S. and to identify key components of effective curricula.

MATERIALS AND METHODSWe searched PubMed using the MeSH as a Major Topic with

the terms “Medical Education, Undergraduate [MeSH]” and “Primary Care.”We filtered our search to include only papers that were published in English (n=1077) from 2005-2015 (n=467). Titles and abstracts were manually reviewed to identify articles describing a U.S. medical school program; this yielded 280 publications. We identified 80 peer-reviewed papers that described an intervention and reviewed each document in full, yielding 18 papers that reported results on the impact of the intervention.

Both investigators reviewed each publication and independently scored it using the Medical Education Research Quality Instrument (MERSQI), a validated measure of

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methodological quality for medical education literature [9]. Any discrepant scores were reviewed and an adjudicated score was assigned based on mutual agreement between the authors.

Emerging themes were identified using an “editing organizing style” [10]. Both investigators independently generated coding templates and then discussed their results, reaching consensus along two main themes.

RESULTSWe included a total of 18 publications highlighting 16

unique primary care programs. Table 1 shows a summary of the publications reviewed with brief details about the content of each program and results reported.

Methodological quality

The quality of publications included in the review varied substantially, and none of the publications described randomization of students to intervention groups. Figure 1 shows published outcomes from the articles, a component of the MERSQI score. Many of the publications included results in multiple categories, all of which are represented in the figure. One program presented patient-level data for individuals cared for by students including clinic visit frequency, no show rates, and preventive care indices measured pre- and post-intervention [11].

Thematic analysis

Thematic analysis of the reviewed publications revealed two primary classifications that helped to further illuminate the characteristics of programs: attention to location (rural vs. urban) and educational format.

Location

A total of 10 articles examining 7 unique programs focused on rural primary care medicine were examined and two articles described urban underserved clinical experiences. All of the so initiatives required students to complete a discrete application to the primary care program in addition to the standard medical school application process.

Rural medicine-focused programs emphasized longitudinal clinical learning at rural sites [12-14], use of technology to link students at disparate locations into a centralized curriculum [12,15], and recruitment of students with rural backgrounds [16,17]. Common strengths of these broad experiences within rural health care systems included engagement with local communities, longitudinal continuity with preceptors, and often-excellent faculty-to-learner ratios.

Outcomes for the studies on rural medicine programs were diverse and ranged from self-rated student confidence in clinical skills to post-residency practice location and specialty. Four of the studies that assessed practice type outcomes showed a higher proportion of graduates practicing primary care compared with non-participating students [12,17-19]. Five of the studies looking at post-residency practice site outcomes found a correlation between participation in their program and rural practice site [12,16-18].

Two programs that provided longitudinal urban underserved clinical experiences were reviewed [11,20]. Students in both

urban programs performed equally well academically to their peers. Participants in one program [20] intended to enter primary care specialties at twice the rate of other students; patients cared for by students in the other program [11] had higher rates of engagement as measured by visit frequency and inter-visit contact.

Educational format

Published studies focused on educational experiences of varying lengths, ranging from four weeks to more than four years (including pre-medical school opportunities). The structure of clinical experiences in the 18 publications reviewed fell into one of four educational formats: isolated elective or clerkship experiences, longitudinal integrated clerkships (LIC), 3rd and 4th year continuous clinical experiences, and primary care tracks of at least four years duration.

Two of the experiences focused on discrete required or elective clerkship experiences [21,22] and two publications focused on LICs [11,23]. The LICs included involved consistent half-day clinical experiences in the same primary care clinic over the course of a year or longer. Results from both types of interventions demonstrated generally positive feedback about the utility and quality of the experiences based on student surveys. In the LICs, participating students had comparable or superior clerkship and standardized testing scores to non-participants. Other longitudinal primary care-focused clinical experiences during the 3rd and 4th years of medical school existed in five reviewed programs [12-15,20,24]. Program length varied from 9 months to two years and often concentrated on clinical immersion in underserved settings. Students were frequently exposed to community-based health centers and satellite clinics of primary academic institutions. Longitudinal preceptorship and mentorship in ambulatory medicine were upheld as key strengths of these programs. A majority of the publications reported outcome data on the residency match [12-14,20] and found overall high rates of residency placement in primary care-focused specialties. There appeared to be academic parity between participants and their non-participating peers, based on USMLE and other exam score data.

Primary care tracks lasting at least four years were examined in 6 unique institutions [14,17,18,25-27], four of which were rural medicine-focused. Shared strengths of these programs included the early establishment of longitudinal primary care mentorship, supplementary coursework in preventive medicine and population health, and ambulatory site immersion similar to the clinical years-focused programs above. Many programs also had focused research workshops and/or research opportunities related to primary care [17,18,25,27]. A majority of programs had available graduation and practice data [14,17,18,27] and found generally increased rates of family medicine and other primary care-focused specialties relative to non-participants.

CONCLUSIONSWe identified a small body of literature describing U.S.

UME programs designed to engage students in primary care experiences and encourage them to pursue primary care careers. Substantial diversity exists in the quality of studies detailing results of these programs, although overall study quality appears to be improving. Longer duration programs and those with an

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Table 1: Published Primary Care Tracks.Name of Program/School Authors Publication

Date Description of Curriculum Program Duration Outcomes Reported

Rural Physician Associate Program (RPAP), University of Minnesota School of Medicine

Power DV, et al [24] 2006

Immersive outpatient clinical experience with rural preceptors, behavioural medicine course, videotaped patient encounters

9 months Pre-OSCE confidence survey, OSCE scores

Medical school participation in school-based health centres (SBHCs), multiple NYC-area institutions

Kalet AL, et al [32] 2007

Independent curricula at each institution, didactics addressing issues related to school health practices, multi-disciplinary focus of on-site training, community service and advocacy opportunities

Varies

Trainee surveys (briefly summarized as "preliminary item analyses")

Brody School of Medicine at East Carolina University

Kerkering KW, et al [25] 2008

Preclinical preventive/population health cases, preventive health history taking, 3rd year postpartum home visit, public health and chronic disease management projects

3-4 years (extends to core clerkships only)

Student surveys

Rural Medical Education Program (RMED), University of Illinois College of Medicine at Rockford

Glasser M, et al [19] 2008

Monthly rural medicine/primary care sessions years 1-3, participatory field trips to rural health organizations, 4th year 16 week preceptorship in rural community with a community oriented primary care (COPC) capstone project

4 years

Recognition/awards, USMLE scores, student surveys, preceptor evaluations, COPC projects, residency match data, post-graduation practice location

Rural Physician Associate Program (RPAP), University of Minnesota School of Medicine

Zink T, et al [15] 2008Community immersion at rural sites supplemented by computer modules, online discussion, and faculty visits

36 weeks Patient log results, end of rotation essays

Rural Scholars Track (RST), Louisiana State University Health Sciences Center School of Medicine - New Orleans

Leblanc KE [14] 2008Clinical clerkships at rural hospital sites, weekly 1/2 days with rural preceptor through 3rd and 4th years

4 years (2 years with unique curriculum)

Residency specialty and location data

Family Medicine Student Track (FaMeS), Boston University School of Medicine

Wilkinson JE, et al [27] 2010

Preclinical placement in core courses with family medicine faculty, monthly preclinical workshops, preference for family medicine summer externship and family medicine clerkship site

4 years (can join at any time)

Qualitative data, residency match data

Telemedicine elective, University of Texas at Galveston

Bulik RJ, et al [21] 2010

Online introductory courses to telemedicine, site visits to telemedicine sites, reflective essay

4 weeks Student essays and multiple choice evaluations

Rural Track Pipeline Program (MU-RTPP), University of Missouri School of Medicine

Quinn KJ, et al [16] 2011

Preadmissions program for rural students, summer community program in 2nd year, 6 month rural track in 3rd year, rural track elective in 4th year

Varies Practice type and location of graduates

Physician Shortage Area Program (PSAP), Jefferson Medical College

Rabinowitz HK, et al [17] 2011

Students with rural backgrounds have preclinical mentors, shadowing, and research in rural family medicine; rural site family medicine clerkship

4 years Residency specialty and location data

Florida State University College of Medicine

Fogarty JP, et al [13] 2012

Clinical training in years 3-4 at 6 regional campuses with local part-time faculty, 70% of time in ambulatory practice

2 years (3rd and 4th year medical school)

Student AAMC survey data, USMLE scores, match data, faculty retention

Primary Care and Special Populations Clerkship, University of South Florida Health, Morsani College of Medicine

Woodard LJ, et al [22] 2012

Disability modules on providing medical care to patients with disabilities, disability-related community based activities, work with model patients with disabilities, stigmatization/isolation modules, home visit

12 weeks

Knowledge, attitude, and comfort in working with individuals with disabilities

RMED, University of Illinois College of Medicine at Rockford

MacDowell M, et al [18] 2013 See Glasser, et al above 4 years Practice type and location

of graduates

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Training in Urban Medicine and Public Health (TRIUMPH), University of Wisconsin School of Medicine and Public Health

Haq C, et al [20] 2013

Immersive experience in an urban health system, 1/2 day per week service learning project, seminars and personal narrative sharing

2 years

Student surveys, mentor evaluations, focus group discussions, grades, USMLE scores, residency match data

University of Louisville Trover Campus (ULTC), University of Louisville School of Medicine

Crump WJ, et al [12] 2013

Clinical training in years 3-4 at a rural integrated health system with didactics streamed from the main campus

2 yearsMCAT, USMLE scores, shelf scores, residency match data

Asheville Longitudinal Integrated Curriculum, University of North Carolina School of Medicine

Heck JE, et al [23] 2014

3rd year students work with outpatient attendings in each of core specialties 1/2 day per week

1 year USMLE scores, residency match data

Rural Track, SUNY Upstate

Roseamelia C, et al [26] 2014

Preclinical rural health curriculum years 1-2, 9 months rural longitudinal placement for 3rd year clerkships, 5 months in same community hospital for electives

4 years

Anticipated practice location and specialty via focus group discussions and in-depth interviews

Education-Centered Medical Home (ECMH), Northwestern Feinberg School of Medicine

Henschen BL, et al [11] 2015

Embedding of students into primary care clinics for 4 years to focus on care and health coaching for high risk patients

4 years

MCAT, NBME, USMLE scores, clerkship grades, survey data, application rates to residency programs, patient outcomes

Figure 1 Outcomes reported in publications.

urban or rural focus appear to have particularly robust results and deserve special attention.

In general, the reviewed interventions have been favorably viewed by students and appear to preserve interest in primary care careers. However, it remains difficult to disentangle the extent to which student self-selection for the interventions impacts this finding. Previous studies in the U.S. and other developed countries have identified a number of contributors to student interest in primary care and rural medicine independent of curriculum including pre-existing interest in primary care/rural medicine, age, gender, and high school location [28-30]. Furthermore, public medical schools generally produce

higher rates of primary care-bound graduates than private medical schools in the U.S. [31]. Therefore, these primary care-focused UME interventions should be viewed in the context of pre-existing student characteristics and self-selection. Our analysis has several important limitations. First, our inclusion of published studies from 2005-15 omitted a number of excellent publications prior to this period. We focused on the most recent data available, acknowledging that these primary care initiatives were informed by many prior experiences. Additionally, we only studied published program results. It is likely that other excellent and deeply impactful programs exist that could not be included here, but are informing the development of newer interventions in other ways. Continued evaluation of primary care educational

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initiatives will help to expand the sparse literature base reviewed here. The dissemination of high quality data among institutions aspiring to galvanize primary care education is crucial to the future of the field. Primary care-friendly national organizations and academic journals have an important role in encouraging and facilitating information-sharing to build a “best practices” model for primary care education.

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Graddy R, Christmas C (2017) The Sparse Evidence Base for Primary Care Initiatives in U.S. Medical Schools. J Family Med Community Health 4(7): 1131.

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