By Pierre Bellicini
Throughout much of the discussion of the current health care reform debate, many recommendations call for increased reliance on primary care physicians. There are estimates that by providing health care for 50 million now uninsured patients, the demand for family physicians and other primary care providers will increase dramatically (Associated Press, MSNBC, 50 million new patients? Expect doc shortages. 9/13/2009).
Those advocating more primary care physicians are urging an increase in medical college enrollment and giving preference to new post-graduate family medicine residencies.
Since the college opened 16 years ago, the Lake Erie College of Osteopathic Medicine has been working to attract medical students into the primary care arena. This is the only medical curriculum of its kind in the United States. By maintaining high quality and affordable medical education, and by adding a new curriculum, LECOM encourages and supports students pursuing family medicine, internal medicine and pediatrics.
LECOM developed an innovative, 3-year medical school curriculum in response to the declining interest in primary care, particularly family medicine. The Primary Care Scholars Program trains primary care physicians more quickly and reduces the tuition and living expenses incurred by students. The pathway compresses the traditional four years of undergraduate medical education into three calendar years by eliminating vacation time and clinical electives while concentrating on those rotations that train medical students in becoming excellent primary care physicians.
Because this pathway is limited to students who know they want to be primary care physicians at the onset of medical school, those elective rotations are not needed, emphasizes Richard A. Ortoski, DO, who chairs LECOM’s Department of Primary Care Education. “Most fourth-year electives simply allow students to explore various specialties and training sites to see what they want to do and where they want to live,” he explains.
PCSP, one of four student-centered pathways at LECOM, stresses basic-science and clinical-sciences education as well as research and community service. The PCSP is equivalent to a 4-year academic program and was granted approval by the American Osteopathic Association Commission on Osteopathic College Accreditation (AOA COCA) in 2006. Presently, there are four third-year Osteopathic Medical Students (OMS3) and seven OMS2; 28 candidates are working toward filling the 10 spaces available for the OMS1 class.
David S. Keith, MPH, OMS3, is one of the four initial students in LECOM’s first group of primary care scholars. He notes that students need to be self-directed “adult learners” to succeed in the accelerated pathway. “This isn’t a process in which all the material you need to master is handed to you,” Keith elaborates. In this pathway, students are given course objectives and outlines but must be disciplined enough to read textbooks and other materials on their own. They interact with faculty members but aren’t required to attend formal lectures similar to LECOM’s independent study pathway.
Keith, who is married and the father of three children finds the time-management challenging but enjoys the flexible hours of PCSP. He also appreciates saving a year of tuition and living expenses with the three-year curriculum. “I am passionate about primary care, and I love being part of something new,” adds Keith, who is 30 years old and grew up in rural towns in Arizona.
The PCSP fosters the educational and personal development of medical students by nurturing:
- Lifelong learning skills and personal responsibility for learning.
- A relevant knowledge base characterized by depth and breadth of information.
- Skills in critical evaluation and acquisition of new knowledge.
Achieving these objectives demands a shift in the curriculum emphasis from teaching to learning and requires students to be active, independent learners and problem solvers rather than passive recipients of lecture-style information.
The PCSP learning modules align with the seven core clinical competencies: (1) osteopathic philosophy and osteopathic manipulative medicine, (2) medical knowledge, (3) osteopathic patient care, (4) interpersonal and communication skills, (5) professionalism, (6) systems-based practice, and (7) practice-based learning and improvement. First-year clinical experiences and ongoing mentoring by primary care physicians over the full 3 years reinforce the connection between the curriculum and these core competencies.
Twenty-eight-year-old Narissa Whitelaw, OMS2, chose LECOM’s Primary Care Scholars Pathway in the fall of 2008 because she wanted to get become a family physicians as soon as possible. “I want to go into family medicine because I like caring for the whole family,” Whitelaw explains. “I want to know my patients and their kids and grandkids,”
“The Primary Care Scholars Pathway is exciting because we get very early clinical experiences, and we learn how to deal with all different types of patients,” Whitelaw adds. “You can have all the medical knowledge in the world, but if you can’t communicate well with patients, you can’t be an effective physician.”
The goal of the primary care pathway is to encourage and enable students who desire careers in primary care to fulfill their aspirations. To modify the 4-year medical school curriculum and deliver it in 3 calendar years requires using available time (i.e., summers) and eliminating redundant medical school electives that students often use to “audition” residency programs in which they are interested.
All critical components of the undergraduate curriculum receive proper and full attention in the PCSP. The first 2 years are the same as those in the other pathways. Following anatomy, PCSP preclinical studies are divided into a core basic-sciences curriculum and a systems curriculum in which students learn the basic and clinical sciences through case-based modules. This case-based knowledge aids them in the proper clinical practice of primary care medicine.
On the first day in the pathway, students are placed with primary care mentors. After rotating with different physicians, each is matched with a mentor who remains with that student until graduation. Faculty members must have attributes and attitudes that embody the ideals of primary care. During years 2 and 3, students meet with their mentors one-half day per month, on average.
The Hospital/Clinical Enrichment Sessions in the first semester of year 2 are devoted to enriching students’ understanding of humanism in all areas and practices of medicine among diverse populations. Here, they observe interactions between the medical team and the patient and family members and also encounter patients themselves.
Mark Haen is another of the original PCSP class. A 2nd Lieutenant in the U.S. Army Reserve, Haen finds the learning modules challenging but rewarding. “As we moved into rotation’s,” Haen explained. “We have all the tools we need to succeed, as well as the added benefit of early clinical training working with our faculty mentors.”
Students complete the basic-sciences curriculum by March of the second calendar year. Entering clinical rotations, students complete 16 rotations in the spring of the third calendar year. The sequence and number of rotations that students begin in March of their second year have been modified to meet the mission and goals of the pathway. LECOM has introduced new core rotations to continue Osteopathic Manipulative Medicine education and other essential primary care medical skills. A final sub-internship rotation prepares the students for postgraduate education at their planned residency institutions.
Rotation sites have been selected from LECOM hospitals based on proximity to the main campus and excellence in primary care clinical training. During year 2 and 3 rotations, students are expected to return to the main campus to participate in monthly Capstone Experiences, they meet with primary care physicians to review basic and clinical sciences in the context of case studies in a modified problem-based learning format.
PCSP students are required to commit to primary care careers and enter a postgraduate program in family medicine, general internal medicine, or general pediatric medicine. Afterwards they may enter a fellowship training program in geriatric medicine or osteopathic manipulative medicine. After graduation from a primary care residency or fellowship, students agree and commit to practice that primary care specialty for a minimum of 5 years. Students who change career paths prior to this 5-year term commitment forfeit their primary care scholarship and must return a full year’s tuition to the college.
By carefully selecting students, assigning primary care mentors, introducing primary care clinical experiences early, and providing enrichment experiences, LECOM intends to influence the supply of primary care physicians locally, regionally, and nationally.
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