TEACHING RESIDENTS THE IMPORTANCE OF COMMUNITY TO HEALTH. E. Jacobs 1 , C. Kohrman 2 , D. Vickers 1 , M. Lemon 1 ; 1 Cook County Hospital, Chicago, IL; 2 Westside Health Authority, Chicago, IL STATEMENT OF PROBLEM OR QUESTION: Many residents care for patients from communities that are very different from their own, yet they rarely have any introduction to the lives, families, backgrounds, and cultural and social contexts of their patients. This is a crucial issue at Cook County Hospital (CCH) where many residents are international medical graduates who have had little exposure to the lives and socioeconomic struggles of our predominantly disadvantaged African American population. OBJECTIVES OF PROGRAM/INTERVENTION: All first-year internal medicine and pediatrics residents participated in the course with the goals of (1) increasing understanding of the US system of health care for disadvantaged groups; (2) improving communication with patients from diverse cultures; (3) increasing appreciation of the complexity of patients' daily lives and how it impacts their health and ability to access health care; (4) enhancing awareness of community and local services' impact on patients' well being. DESCRIPTION OF PROGRAM/INTERVENTION: The curriculum consists of 5 teaching modules taught by faculty from CCH and the Westside Health Authority (WHA), a community health advocacy organization, in 4 half-day sessions over a month-long ambulatory rotation. The first module is a case-based overview of the financing of care in the US with a focus on Medicaid, Medicare, and the impact of insurance status on health. The second module addresses problems language or culture can create in patient encounters. The third module uses a case study of opening an ambulatory clinic in a diverse neighborhood to teach about community based primary care. The fourth and fifth modules focus on the community and its citizens and are taught by citizen leaders and a sociologist. In the fourth session, the citizen leaders lead a discussion about their community and their experiences with the health care system. In the fifth session, residents have lunch with citizen leaders in the community and are given an introduction to the neighborhood and to the mission and activities of WHA. FINDINGS TO DATE: More than 50 internal residents participated in the curriculum. The evaluations of the program have been uniformly positive, with many residents indicating that it has changed the way they think about their patients and their health care. A majority has also asked that more teaching time be dedicated to these topics. An unexpected benefit has been the education and empowerment of the citizen leaders. They came to see physicians in a new light, as accessible human beings, and learned so much about health and health care that they became community health advocates. KEY LESSONS LEARNED: Residents are eager to learn about the lives, cultural and social contexts of their patients and value this kind of teaching. Communities and residency programs can create mutually beneficial relationships in the common pursuit of improved patient care and community health. national demonstration project Ð and the acquisition of a large regional primary care network (Clinical Care Associates) provided the opportunity to introduce students to the community practice environment. Our primary goal is to develop a cohesive academic primary care network for both clerkship and residency education. The specific objective of the present component of this broad initiative was to assess medical students' satisfaction with the community training environment by comparing their evaluations of newly-recruited community preceptors with those of more experienced hospital-based preceptors. DESCRIPTION OF PROGRAM/INTERVENTION: The core clinical clerkships in medicine (12 weeks) and pediatrics (6 weeks) are both equally divided between inpatient and outpatient experiences. Three weeks of the medicine clerkship are spent in a general internal medicine practice, three weeks in a family medicine practice, and six weeks in an inpatient setting. Pediatrics is comprised of three weeks in an outpatient setting and three weeks on an inpatient service. Outpatient preceptors work in 1:1 relationships with students. FINDINGS TO DATE: In the 1995 ± 96 academic year, primary care clerkship students spent a total 483 half-days in an outpatient environment, all as part of the internal medicine clerkship. Today, students spend 10,720 half-days annually in physicians' offices (internal medicine=3840, family practice=3840, and pediatrics=3040 half-days, respectively). Every student receives a minimum of 72 half-days of ambulatory (predominantly community-based) primary care training during their core clinical clerkship year. Using 9-point Likert scales in up to 15 different categories, students' ratings of newly recruited community internists and pediatricians compared very favorably with those of more experienced hospital-based preceptors. Community family physicians were more highly rated than a core group of residency-based family physicians. KEY LESSONS LEARNED: Despite the increasing demand for clinical productivity, community faculty accepted medical students with enthusiasm, and students were delighted with the opportunity to work closely with community primary care preceptors. The positive responses from students indicate that the integration of community practice experiences into the undergraduate curriculum will provide medical schools with the opportunity to expose students to diverse role models and a wide spectrum of patients in very favorable settings. The SP is a free health clinic that was started in 1996 by Tufts University medical students and volunteer physicians. The SP's mission is to improve the Chinatown community's access to health care by providing initial care and then facilitating referrals to ensure continuity of care. The clinic space is donated by a local church and laboratory services are donated by a local laboratory. A grant from the Massachusetts Medical Society, technical support from the New England Medical Center, and an annual, student-run auction, allows the SP to provide services free of charge. First and second year medical students handle the clinic's management and administration; they act as physician's assistants, case managers and medical interpreters. Students are supervised by volunteer physicians. Since 1996, the clinic has continued to expand and now offers the following: General medical care every Tuesday, 6 ± 10 PM, year round; Psychiatric and gynecological services; Onsite EKG machine and phlebotomy; Free medication samples; Referrals to primary health care providers, specialists, dentists, and optometrists; Adult and child immunizations; Anonymous HIV counseling and testing. FINDINGS TO DATE: Over the past 5 years, more than 400 medical students have volunteered at the SP. First-year medical students take over project management mid-year. The SP's success is a result of the dedication and innovation each class brings to the project. Medical students from Boston University and Harvard, as well as residents from the New England Medical Center have become involved and now contribute to the project. The following are demographics for the 1528 patient visits from 02/97 ± 12/00: Ethnicity(%) Chinese=81.7, White=9.8, Black=2.7, Hispanic=1.3; Age of Patient(%) 0 ± 19=4.7, 20 ± 39=29.2, 40 ± 59=32.2, 60+=33.9; Health Insurance(%) Yes=20, No=76. KEY LESSONS LEARNED: The SP provides an educational model for medical schools around the country. It is an example of how medical students can establish and manage a free health care clinic and actively participate in patient care during their pre-clinical years. We have learned that it is important to stress the mission of the SP to its patients. The SP is not a substitute for primary care delivered to Chinatown residents. The SP is a place where medical students can begin to take responsibility for patient care and patients can begin to access the American health care system. In an ideal teaching environment medical interns and residents are expected to assume total care of teaching patients. When the residents are bypassed in the decision making process, it is likely due to a communication problem which leads to attending physicians writing orders directly. Despite repeated efforts to dissuade attendings from writing orders at our community based program we decided to look at what other factors may contribute to this. OBJECTIVES OF PROGRAM/INTERVENTION: The goal was to improve communication between house staff and attendings and to ultimately decrease attending order writing on teaching patients. In addition we wanted to see an increase in satisfaction by the house staff, nursing staff, and attendings with the communication process. DESCRIPTION OF PROGRAM/INTERVENTION: A team consisting of house staff, nursing staff, and attendings met on a regular basis to identify key issues impeding good communication. Using an interrelationship diagraph the most important issue was identified as the nursing staff directly calling attendings on management issues, due to difficulty in identifying the house staff carrying their patient. The following interventions were developed to facilitate better identification and location of house staff. First, the intern's name and beeper number were entered on the nursing station board, as well as in the computer system which printed it daily on the nursing cardex. Second, the interns were issued personal non-cellular phones to provide direct communication with nurses and attendings. Third, the nursing station board was updated daily identifying the house officers on call. Fourth, the interns and residents were required to twice daily update their status on their beeper voice messages. Outcome measures used were orders written per patient by attendings as identified by a weekly log kept by the house staff. Second, there was a monthly survey of nursing staff, house staff, and attendings of their satisfaction with the communication process. FINDINGS TO DATE: The average number of orders written per chart by attendings was 1.7 and showed no substantial variation on a run chart since the beginning of the intervention. Poor return on the satisfaction surveys has limited any useful interpretation at this time although efforts are being made to increase their return. KEY LESSONS LEARNED: KEY LESSONS LEARNED: First, we learned that the major barrier to the communication process was the difficulty in identifying or locating the appropriate house staff. Second, we learned that the motivation for writing orders by attendings is multi factorial and often system related. We will continue to identify those other components that may contribute to order writing as we track the above outcomes. This program serves as a model that provides a proven approach to community-based learning for medical students which is translatable to traditional Western medical educational systems. DESCRIPTION OF PROGRAM/INTERVENTION: The COBES program implemented at MUFHS over the past ten years provides a valuable model for community-oriented education. The current program comprises approximately 27% of the curriculum for medical students at this nascent medical school in Eastern Africa. Under this program, students spend classroom time developing knowledge of research methodology, epidemiology and public health initiatives. During three years of the curriculum, they spend three to six weeks per year in rural communities learning community interaction skills, public health intervention, and health administration skills. In addition, they spend two years designing and implementing research projects within an urban community of their choice. FINDINGS TO DATE: Focus groups with students and faculty have demonstrated overwhelming support for the value of this community-based educational program in Kenya. Students have gained valuable training and experience within communities, experienced crosscultural interactions and have been able to conduct relevant descriptive and interventional research projects. COBES projects have won international awards for student research, but more importantly, the findings have been useful in creating public health initiatives for a variety of communities at a local level. KEY LESSONS LEARNED: The COBES program at Moi University provides an important model for community-based education that can also be applied to the Western system of medical education. The community interaction skills, public health knowledge and research techniques gained by the students will benefit them in any future endeavors, whether in a subspecialty, research or in community practice. While the immediate value of these types of programs is obvious, further observation and research will be needed to demonstrate the longlasting effects of this model of community-based education on the makeup and practice of medical practitioners in the future. Texas, provides educational services for clinicians. The medical education director of TOAETC served as consulting physician (CP) for this project. In July 2000, a 1800 number was established to accept requests for patient specific consultations from providers in Texas. The number was advertised by: 1. Mailing brochures to potential HIV medication prescribers (n=17,000); 2. Distribution of brochures at TOAETC sponsored lectures (n=421); 3. Two day clinical trainings in which the CP engaged in hands on patient care with community based HIV providers, and personally distributed the TOAETC brochure (n=24). Electronic consultations involved Email, faxes, websites, digital photography, as well as phone conversations. Examples will be displayed. All consultations were completed within 24 hours of the request. FINDINGS TO DATE: Forty-six patient specific consultations were performed between July 5, 2000 and January 5, 2001. The vast majority (87%) of requests for consultation came from community providers with whom the CP had engaged in a two day clinical training (n=40). Six requests came because of referrals from the CP's colleagues. No patient specific consultations stemmed from either the mass mailing or the direct appeals at TOAETC sponsored lectures. Total cost for the mass mailing was $36,545. Total cost for the clinical trainings was $6232. Interestingly, all requests came via the CP's private office number or his private email. The 1800 number was not utilized for its intended purpose of facilitating consultation. KEY LESSONS LEARNED: Community HIV providers are willing and able to link with providers at tertiary care centers via electronic consultation. However, our experience suggests that they are not likely to utilize electronic consultation methods without first establishing a professional relationship between consultant and consultee, as can be accomplished in a cost effective two day clinical practicum. STATEMENT OF PROBLEM OR QUESTION: Community-based educational programs pose challenges that include providing a high quality consistent curriculum across teaching sites and reducing student isolation. OBJECTIVES OF PROGRAM/INTERVENTION: To provide an interactive all day educational experience for students in our community-based medical school. Education Day is designed to: 1) Provide consistent high quality instruction for all students in key areas of the clerkship curriculum; 2) Allow students to learn from our best teachers; 3)Provide a recruiting opportunity for our community-based residency programs; and 4) Demonstrate the fun and intellectual challenge of internal medicine. DESCRIPTION OF PROGRAM/INTERVENTION: Students at our institution receive their clinical training in one of six community campuses located throughout the State. Students in the Medicine Clerkship travel to one campus for an all-day educational experience. The program includes three large group sessions and five small group workshops. Master teachers chosen from each community conduct the sessions. The three large-group sessions include: 1) Acid-Base Interpretation, an interactive lecture; 2)``Thieves Market'' where students try tò`s teal'' the diagnosis in a series of progressively disclosed cases; and 3)``Stump the Chump'' where the department chairman``thinks aloud'' working through a series of difficult clinical cases in a CPC-like format demonstrating the thought processes of an internist. Small groups of students rotate through each of five workshops, which are interspersed between the large group sessions. They include: 1) The Bedside Cardiac Exam using a Harvey (r) mannequin; 2) Starting IVs with Confidence using models and an interactive computer program; 3) Dynamic ECG Interpretation; 4) Chest X-Ray Interpretation; and 5) Utilizing the Peripheral Blood Smear. FINDINGS TO DATE: We have conducted two iterations of Education Day that included 70 students. Written and oral feedback has been overwhelmingly positive with some suggestions for minor changes. Students expressed specific appreciation for the quality of the program, a chance to see their colleagues at other campuses, and a break from the tedium of their clinical responsibilities. Several students requested expanding the program to two days. KEY LESSONS LEARNED: Education Day is one approach we have used to address the challenges of community-based education. Although it is not the entire answer, we are pleased with the initial results. While the feedback from students has been overwhelmingly positive, we look forward to assessing whether Education Day has achieved other desirable outcomes including improved shelf exam scores and an increased interest among our students in a career in internal medicine. STATEMENT OF PROBLEM OR QUESTION: Our Internal Medicine ambulatory rotation hosts a variety of learners with separate calendars and needs, and our many faculty members had their own sets of performance expectations. We had no consistent orientation process for these learners. OBJECTIVES OF PROGRAM/INTERVENTION: 1) to have an orientation program for our ambulatory site listing expectations for medical students, physician assistant students, Internal Medicine residents and Gynecology residents 2) to develop an orientation program using a minimum of faculty time and available to learners at any point during the rotation DESCRIPTION OF PROGRAM/INTERVENTION: Working with the Educational Technology Lab at MUSC, we developed an electronic, on-line orientation program for our Internal Medicine ambulatory block that can be navigated in a learner-specific fashion. This includes a virtual tour of the clinic, an overview of the patient population and expectations for medical students, physician assistant students, Internal medicine and Gynecology residents. We will present the orientation on computer notebook for perusal by attendees, and will discuss the development of the program. FINDINGS TO DATE: The orientation has been well received by faculty, staff and students. The amount of faculty time spent in orientation has been minimal. We are currently gathering formal feedback that will be available for the presentation. KEY LESSONS LEARNED: Learners must be given a set of expectations that should be communicated to them in a timely and consistent fashion. This on-line orientation is engaging, readily available and easy to update. STATEMENT OF PROBLEM OR QUESTION: With the increased demands on teaching faculty time, the need for standardized methods to assess the acquisition of auscultatory and observational skills of students is required. OBJECTIVES OF PROGRAM/INTERVENTION: This module was developed and administered to test clinical skills for medical students as part of their introduction to clinical medicine course, with focus on cardiac and chest auscultation as well as determination of radiological images findings. DESCRIPTION OF PROGRAM/INTERVENTION: A computer software (Question mark Perception) was used to present five clinical scenarios to the students. Each followed by five to six multiple choice, one-best answer questions. Radiological images (. jpg format) and sound files (. wav format) were used to present common cardiac and period in the fall of 2000. A total of nine computers were available in the Learning Resource Center of the library. Library staff members lung findings. The exam was administered to 143 second year medical students over a one-week proctored the exam. The exam was scored with the same software (Question Mark Perception) FINDINGS TO DATE: The average time the students used to complete the test was 47:35 minutes. Minimum time was 4:13 minutes and maximum time was 2 hours and 21 minutes. Of the total class, 84 % of the students took the exam in the last two days. There was virtually no waiting time, although one student where he had to wait for 5 minutes for a computer to be available. The maximum score obtained was 97%; minimum score was 58%. The software program reported the mean score, the standard deviation and degree of difficulty of each question. One question was eliminated from scoring because the sound quality was poor. KEY LESSONS LEARNED: Computer based testing of clinical skills needs further development, but is currently feasible. We plan in using the same software for an exam in spring 2001. This method of testing can also be expanded for use in clinical clerkships as well as assessing clinical skills of house staff. STATEMENT OF PROBLEM OR QUESTION: Clinical practice in community sites is an integral part of our primary care internal medicine training program. Despite this, many of our residents remained unfamiliar with the practice of community-oriented primary care (COPC). In order to teach them about and encourage them to practice COPC, we developed an eightweek course in community medicine. In conjunction with this course, we designed an intranet website to facilitate rapid learning of COPC. OBJECTIVES OF PROGRAM/INTERVENTION: The goals of our intranet site were to: 1) provide residents with readily accessible information about community medicine; 2) prompt residents to consider, discuss and learn about COPC on a near-daily basis; and 3) introduce distance learning concepts into the residency program. DESCRIPTION OF PROGRAM/INTERVENTION: We located an internet website (http:// intranets.com/) that supported the creation of free intranet sites. Once created, access to the intranet site was restricted to the primary care residents and selected faculty. The intranet site (http://pcimcommunitymed.intranets.com) featured discussion groups, documents and readings, links to important public health internet sites and a weekly course calendar.