- Claire Fung, MD/MPH Candidate & Jessica Schumer, MD Candidate Tulane University School of Medicine, New Orleans, LA [Forum Discussion]

From May 2007 to July 2008, six Tulane University medical students, originally from various parts of the United States and Canada, found a home in the small town of Pierre Part, Louisiana.  What began as a Tulane Family Medicine Clerkship to inspire and support a culture of health and wellness in this small community of roughly 3,500 people became a partnership that would unite the medical and public health community; local, regional, and national government; schools; businesses; and families.  This initiative was thoughtfully named “JumpStart Pierre Part”.

Pierre Part, Louisiana is located approximately 75 miles northwest of New Orleans.  The town was landlocked until the 1970s, and as such is home to a tight-knit Cajun population with only one full-time primary care clinic.  Despite their efforts in nutrition and exercise counseling at every doctor’s visit, the town’s two family physicians had developed a growing concern about childhood obesity and metabolic syndrome in the community.  In addition, Pierre Part lacked playgrounds, sidewalks, and a communal engagement towards healthy living.  JumpStart Pierre Part quickly became a huge success.  In just months, our JumpStart team, with the support of Pierre Part’s family physicians and town council, labeled healthy choices in the local grocery store and established a nutrition and exercise curriculum at Pierre Part Elementary School that reached beyond the classroom.  We involved families, inspired Kindergarten and Pre-K parents to change classroom snacks to healthier options, and started a dialogue about health and wellness that was to be reinforced through weekly articles in the local newspaper, as well as community events such as cooking classes and the annual health fair and food festival (Supplemental Figure 1).

When we presented our experiences and findings from JumpStart Pierre Part to colleagues and at local and national meetings, we were often asked: “How did you make this project a success?”  After multiple evaluations and analyses, we have since concluded that the answer lies in our model, which is rooted in a fundamental belief in and application of primary care and community health principles (Supplemental Figure 2).  We believe that in order to create a health care workforce equipped to provide a high-value team approach to coordinated, patient-centered health care, we must redesign the medical school curriculum such that it grows from a foundation of primary care and community health.

As a profession, it is critical that we re-establish the central role of primary care and affirm the value of a team-based approach.  The need for reform is evident both locally and nationally.  Currently, 97% of Louisiana parishes have areas classified as Primary Care Health Professional Shortage Areas (HPSAs)¹.  Nationally, nonmetropolitan areas, which include more rural areas, have substantially fewer primary care physicians per 100,000 people (55 per 100,000 vs. 93 per 100,000 in metropolitan areas)².  This shortage correlates with the low numbers of US medical school graduates choosing residency in primary care fields (an average of 8.4% of US medical school graduates chose Family Medicine for residency from 2005-2007)³.  Ultimately, the way to help meet the health care needs of this nation is to increase the number of primary care physicians.  We believe this should start at the medical education level, where we must engage students in meaningful community health initiatives and teach them the fundamental principles of primary care.

The reform of medical education has been the topic of numerous reports and forums^4,5,6 in recent years,  and multiple groups have been proponents of a diversification of the curriculum7,8, especially in the “pre-clinical” years.  It is now generally understood that the solution to improving medical education is a multi-faceted one, and begins with the incorporation of more social and political aspects of health care delivery into the medical school curriculum.  Crucial to the patient-centered approach is the recognition by the physician-in-training that the patient exists within a dynamic environment and that his/her determinants of health not only include genetic or biologic factors, but are also profoundly influenced by his/her familial relationships, socioeconomic status, level of education, and access to resources.  The growth from a primary care foundation begins with the very definition of “primary care” ― its inclusion of disease prevention, health promotion and maintenance, counseling, and patient education, all in addition to the diagnosis and treatment of illness.  We propose that teaching medical students to consider the patient as a whole must involve the pursuit of a longitudinal community health project, not unlike JumpStart Pierre Part, by each student in the course of his/her time in medical school.

In recent years, many medical schools have begun to shorten traditional didactic lecture-time for students, relying instead on small-group discussion, self-instruction, laboratories, and case-studies.  In addition, medical students have been increasingly offered more exposure to essential topics such as the doctor/patient relationship, medical ethics, nutrition, and population health9.  We propose formalization of these topics within the curriculum― changing their current “auxiliary” or “selective” status to “requirement” status.  To gain experience in clinical skills, students would shadow clinical nurses and EMTs, practice in a simulation laboratory, learn the relevance of computers in medicine from experts in medical technology, and compare firsthand how rural and urban health care settings deal with the difference in available resources.  As prevention plays a critical role in all disease states, students would have the opportunity to visit the local or state department of health, learn from a partnering dentist, teach a lesson at a high school or school clinic, and attend community-based health and wellness classes.  All students would gain exposure to the local Women, Infants and Children (WIC) and Planned Parenthood offices.  Another essential piece of medical education is to learn how physicians serve as advocates and influence policy change.  To acquire some of these vital skills, students would meet with a hospital CEO, a community health center or federally-qualified health center CEO, and health professionals serving as lobbyists.  Students would also be introduced to and have the opportunity to work with individuals who advocate for patients every day, including social workers and hospital case managers.  Exposure to medical-legal partnerships, and medical-business partnerships would help students better understand the issues surrounding malpractice and public versus private medical insurance.  Students would gain an appreciation of the basic sciences and research by spending time on the laboratory bench and would see the direct application of such work in pharmaceutical development.  In order to emphasize the role of public health in medicine, students could work with a state epidemiologist, meet with a global health specialist, and see patients at a local homeless shelter or prison.  We believe that each of these opportunities is pivotal in cultivating a well-rounded, patient-centered health care workforce in which physicians not only appreciate all the determinants of health, but are able to apply the lessons learned from each of these interactions to their future practice of medicine.

Although much time and consideration have been given to updating medical school education so that it more accurately prepares students for the current practice of medicine10, many institutions are finding it hard to achieve true change due to a variety of barriers: lack of staff to teach or funding to implement the newly designed courses, time constraints and problems with scheduling, and an overall resistance to change11.  We believe that the best way for students to internalize knowledge about the determinants of health learned in the pre-clinical years is for each student to embark on a longitudinal project over the course of their third and fourth years of medical school.  The student would first establish a potential area of interest within the medical profession.  The next step would involve the identification of a need within the specified field of interest.  Then, the student would begin to formulate an approach to solving the problem or meeting that need.  Students would receive mentorship from a practicing physician in the community.  The basis for the longitudinal project can be found in the following belief: each medical student should make a meaningful contribution to his/her field of interest in hopes of not only gaining valuable experience in that field, but also developing a better understanding of how all the components of the health care system are intertwined and interact with one another.

Figure 1.  Medical Education Model

As a representation of our curricular redesign, we have aligned our medical education model with the sprout of a great oak tree, common to the streets of New Orleans.  The soil, providing life and support to the nascent sprout, is composed of the foundation of the first two years of medical education: an appreciation and understanding of primary care and community health.  Also in this early stage of development, each physician-in-training would be exposed to the essential principles of basic sciences and research, clinical skills, prevention, advocacy, policy, and public health.  By the end of the first two years, students would have a strong foundation from which they could start to pursue their specific field of medicine.  Over the course of the next two years, students would begin to grow into a more mature tree, with their specific interests driving the choice of a hands-on project that offers the opportunity to apply the acquired knowledge and skills from the first and second years, as well as contribute to their potential field of study.  Ultimately, the student would develop into a grand oak, with the ability to matriculate into the specialty of their choice and hone in on the areas most relevant to their future careers, but with the understanding that the patient exists at the center of a dynamic environment.  This model would not only encourage more medical graduates to pursue a career in primary care, but would also propagate a new generation of physicians who are able to treat the patient as a whole instead of simply treating the disease at hand.

Although there are many variables that influence a medical student’s career choice, one of the most important changes that can be made in medical education to promote primary care specialties is to present the field as a central tenet of medicine, one that is very highly respected and valued.  By redesigning the curriculum so that primary care and community health are at the core and such that students are exposed early on to mentors in primary care disciplines, we believe that more people will maintain their original interests in primary care upon entering medical school as well as be drawn to the profession due to its emphasis in their training.

It is said that an oak tree can live for over one thousand years.  In order for the tree to survive, however, it must have its roots planted in a solid foundation and be able to withstand the ever-changing environment.  Similarly, in order for our profession to continue to evolve over time, we must begin our education with a foundation grounded in primary care and community health, encouraging students to not only treat the patient’s disease but to consider every determinant of health.  JumpStart Pierre Part was a success because we were able to apply and incorporate what would normally occur in one doctor’s visit into all aspects of the patient’s life.  Success came in the realization that in order for one patient to change his/her eating habits, we needed to do more than tell him/her so in our fifteen-minute clinic visit.  Beyond this interaction, we had to consider the patient’s shopping habits, family dynamics, and physical environment.  In learning to appreciate all of the influences on a patient’s health through JumpStart, we accomplished more in medical school than we could have ever imagined.  Each of the six medical students who were originally involved has chosen a career path in primary care, and JumpStart continues to inspire future primary care physicians.

In summary, we believe that medical education requires an entire paradigm shift, transferring the focus from the current disease-based model to a new foundation based on primary care and the ability to advocate for a patient and his/her community.  In this way, we will create a professional work force that understands that medical knowledge is only the first step in truly treating their patients.  By engaging in a longitudinal, community-based project, the future generation of physicians-in-training would not only be challenged to work as a team and think critically, but they would also see firsthand that physicians have incredible power outside of the clinic and hospital to effect change at the individual patient level, the community level and the policy level.

References:

1. Morgan, K.O. and Morgan, S. (Eds.) Health Care State Rankings 2003: Health Care in the 50 United States. (11th Ed.) Lawrence, KS.
2. Steinwald, AB. Primary Care Professionals. Recent Supply Trends, Projections, and Valuation of Services. Government Accountability Office Report, Feb. 12, 2008.
3. McGaha, AL, Schmittling, GT, DeVilbiss, AD, Pugno, PA. Entry of US Medical School Graduates Into Family Medicine Residencies: 2007–2008 and 3-year Summary.  Family Medicine 2008;40(8):551-62.
4.  Health Professions Education: A Bridge to Quality.  Institute of Medicine, 2003.
5.  Training Tomorrow’s Doctors: The Medical Education Mission of Academic Health Centers.  A Report of The Commonwealth Fund Task Force on Academic Health Centers.  April, 2002.
6.  Educating Doctors to Provide High Quality Care: A Vision for Medical Education in the United States.  Report of the Ad Hoc Committee of Deans, July 2004.
7. Whitcomb, ME. The general professional education of the physician: is four years enough time? Academic Medicine 2002;77:845-46.
8. Hoover, EL. A century after Flexner: the need for reform in medical education from college and medical school through residency training. Journal of the National Medical Association 2005. September 97(9):1232-9.
9. “The Medical Student Education Program.” 2009.  AAMC Curriculum Directory. 8 March 2009. <http://services.aamc.org/currdir/about.cfm>
10. “U.S. Medical Schools Teaching Selected Topics 2008 LCME Part II Annual Medical School Questionnaire” Hot Topics in Medical Education. 2008. AAMC Curriculum Directory. 8 March 2009. <http://services.aamc.org/currdir/section2/04_05hottopics.pdf>
11. Educating Medical Students: Assessing Change in Medical Education. The Road to Implementation. ACME-TRI Report.  1992.

Supplemental Figure 1: JumpStart Pierre Part photo journal. (a) Claire Fung (MS4) & Dr. Sherlyn Bell Larrison conducting a cooking/nutrition class on Fiber at the local library. (b) Green-Light Foods display at the Pierre Part Store. (c) Katie Hall (MS4) giving a lesson to students of Pierre Part Elementary for February’s “Healthy Hearts” challenge. (d) JumpStart Program Coordinator and Bayou Journal columnist, Linda Cooke, planting seeds in the school garden. (e) Randi Sokol (MS4) teaching kids “Healthy Habits”. (f) Jessica Schumer (MS4) introduces “Eat a Rainbow”-week. (g) Staff at the Larrison Family Health Center all dressed up for JumpStart team spirit! (h) Without any input from the JumpStart initiative, students at Pierre Part Elementary decided on a Healthy Food theme to this year’s Mardi Gras parade.

Supplemental Figure 2. The JumpStart Pierre Part Model