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Academic Medicine:
Institutional Issues: Articles

An Integrated Residency in Internal and Preventive Medicine

Katz, David L. MD MPH; Nawaz, Haq MD MPH; Ahmadi, Ramin MD MPH; Jekel, James F. MD MPH; DeLuca, Vincent A. MD; Cashman, Suzanne DSc; Fulmer, Hugh S. MD MPH

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Author Information

Dr. Katz is director, Preventive Medicine Residency Program and the Yale-Griffin Prevention Research Center, Department of Preventive Medicine, Griffin Hospital, Derby, Connecticut, and director of medical studies in public health and assistant clinical professor of epidemiology and public health and medicine, Yale University School of Medicine, New Haven. Dr. Nawaz is assistant director, Preventive Medicine Residency Program, Department of Preventive Medicine, Griffin Hospital; assistant research director, Yale-Griffin Prevention Research Center; and lecturer in public health, Yale University School of Medicine. Dr. Ahmadi is assistant chairman of graduate medical education and assistant director, Internal Medicine Residency Program, Griffin Hospital; and assistant clinical professor of medicine and lecturer in public health, Yale University School of Medicine. Dr. Jekel is associate director, Preventive Medicine Residency Program, and chairman, Department of Preventive Medicine, Griffin Hospital; and professor emeritus of epidemiology and public health, Yale University School of Medicine. Dr. DeLuca is chairman of graduate medical education and director, internal medicine residency program, Griffin Hospital; and clinical professor of medicine, Yale University School of Medicine. Dr. Cashman is associate professor, Department of Family Medicine and Community Health, University of Massachusetts Medical School, and Dr. Fulmer is director, Center for Community Responsive Care, Boston, Massachusetts.

Correspondence and requests for reprints should be addressed to Dr. Katz, Preventive Medicine Residency Program, Griffin Hospital, 130 Division Street, Derby, CT 06418; e-mail:〈katzdl@pol.net〉.

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Abstract

The importance of preventive and population-based principles in clinical practice is widely acknowledged. The challenge of imparting these principles in either under-graduate or postgraduate medical education has, however, not been fully met. The necessary skills are provided comprehensively by preventive medicine residency programs, but at the expense of clinical training. Sequential residencies in primary care and preventive medicine, the currently available means of obtaining thorough preparation in both clinical and population-based principles, represent an inefficient, generally unappealing, and non-integrated approach.

In response to these concerns, and in an effort to make preventive medicine training appeal to a wider audience, the authors developed and implemented a residency program fully integrating internal and preventive medicine. The program meets, and generally exceeds, the requirements of both specialty boards over a four-year period. The program provides extensive training in clinical, preventive, and public health skills, along with case management and cost-effective care, conferring the MPH degree and leading to dual board eligibility. The model is ideally wed to the demands of the modern health care environment in the United States, is extremely attractive to applicants, and may warrant replication both to train academic and administrative leaders and to raise the standards of preventive and public health practice in primary care.

The acquisition of preventive medicine knowledge and skills, emphasized in the Flexner report,1 is increasingly recognized by both academic and provider organizations as essential preparation for medical practice.2–10 However, incorporation of the full scope of preventive medicine—from public health to occupational medicine to clinical prevention—into the crowded curricula of medical schools and clinical residencies is a daunting challenge. A variety of curricular innovations have been developed, with variable success,11–14 but no systematic approach to incorporating preventive medicine into either undergraduate or postgraduate training has emerged.

One way to ensure adequate training in prevention and its related content areas is through residency training in preventive medicine. A preventive medicine residency consists of a clinical year, as academic year leading to a master's degree in public health (MPH), and a practicum year comprising various rotations in public health practice and clinical prevention. Specialty boards in preventive medicine have been available since 1948. However, preventive medicine suffers from a low profile.15,16 In our experience, medical students considering residency alternatives are often surprised to learn that preventive medicine exists as an option or learn of it late; a majority of preventive medicine residents report prior residency training or clinical practice experience.17 For those students aware of training in preventive medicine and public health, the choice between a clinical or public health career may pose a dilemma. The integration of public health training into medical school offers one resolution, but either shortchanges another component of the curriculum (if students are to graduate in four years) or adds an additional year (during which students are, at best, unsalaried or, at worst, required to pay tuition).18 While some efforts at integrating prevention into medical school have been offered as models, most schools have met with considerable difficulties,19 and concern has been expressed regarding the feasibility of systematic inclusion of such content.20

As an alternative, opportunities may be sought to teach prevention during postdoctoral residency training. More than a decade ago, the Society for Research and Education in Primary Care Internal Medicine concluded that preventive health care in general internal medicine residency training was not adequate.21,22 Most of the residency programs in the country lack structured teaching of preventive medicine of occupational medicine to their residents.23–26 Concerns similar to those raised regarding space in existing undergraduate curricula for additional content have been voiced regarding residency training, however; obstacles to the systematic inclusion of population-based and preventive medicine content in the training of either medical students or residents have been acknowledged at meetings of the American College of Preventive Medicine.27

In response to these concerns, we developed a residency program fully integrating internal and preventive medicine training over a four-year period at a community hospital (Griffin Hospital in Derby, Connecticut) in affiliation with the Yale University School of Public Health and the Yale University School of Medicine. The program exploits the intrinsic synergies of medicine and public health, using affiliates of the preventive medicine program as sites for innovative clinical electives (e.g., occupational medicine, ambulatory managed care), and resources of the internal medicine program as opportunities for applying clinical prevention or conducting clinical research. Residents meet and, in general, readily exceed all requirements for board eligibility in both internal medicine and preventive medicine and obtain an MPH degree from Yale. Residents are salaried for all four years, including the time spent in the MPH program. This article describes the details of the model and our experience to date.

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PROGRAM DESCRIPTION

Program Development

Griffin Hospital (an affiliate of the Yale University School of Medicine) had a fully accredited residency in internal medicine (IM) at the time the program was initiated. Following lengthy negotiations with representatives of the residency review committees (RRCs) of both internal and preventive medicine, as well as representatives of both boards, the program was implemented in 1995 through an affiliation with the Center for Community Responsive Care in Boston, MA, which had accreditation for a preventive medicine residency.28 Neither board endorsed the concept of a “combined” residency, but each expressed a willingness to accept the program provided that all of its eligibility requirements were met in full.

In 1996, Griffin recruited two physicians on the faculty of the Yale School of Public Health to coordinate development of an independent preventive medicine (PM) residency. Both faculty were board certified in general PM, and one had boards in both IM and PM from sequential residencies. The PM faculty worked closely with the IM faculty at Griffin to fully integrate the two programs over a four-year period, mindful that no “shortcuts” were permissible to either board. In January 1997, a meeting devoted to combining primary care and preventive medicine training was sponsored by the Health Resources and Service Administration in Washington, DC, at which the program was presented along with approximately a half dozen related models. The program was also presented at Prevention '97, the annual meeting of the American College of Preventive Medicine and Association of Teachers of Preventive Medicine, in Atlanta, Georgia. An application was submitted by Griffin to the preventive medicine RRC at the Accreditation Council for Graduate Medical Education (ACGME) for an independent PM residency in February 1997. The application fully described both the two-year content of the PM residency and its distribution over the four years of integrated training. The PM residency at Griffin received provisional accreditation notice in December 1997, retroactive to July 1, 1997, and the first resident graduated from the program in June 1998.

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Detailed Structure

The IM residency at Griffin currently accommodates nine PGY1 residents. There are five positions in both PGY2 and PGY3, three of which are categorical medicine, and two of which are allocated to the integrated program. The two residents in the program continue into PGY4. Thus, at present, a total of eight residents may be enrolled in the program at any given time. With the approval of the RRC in preventive medicine, the program will be expanded to replace all categorical IM positions with integrated residency positions. Plans call for either four or five positions in each of PGY1 through 4; as of December 1998, permission has been granted to expand to three. The basic structure of the four-year curriculum is shown in Chart 1.

Chart 1
Chart 1
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PGY1

The internship during PGY1 is conventional, in compliance with requirements of the American Board of Internal Medicine (ABIM), and in fulfillment of the requirement of the American Board of Preventive Medicine (ABPM) for a clinical year in a primary care discipline. Residents begin their duties on or about July 1 of each year, and finish on or about June 30 of the next year.

Interns in the program have no responsibilities beyond those of interns in the three-year IM residency, but they are provided additional opportunities. Time permitting, integrated-program interns attend biweekly research meetings and participate in ongoing clinical research. They are also encouraged to attend a preventive medicine seminar held weekly during the academic year at the Yale School of Public Health. Finally, attending physicians trained in both preventive and internal medicine serve as ward and clinic teachers, orienting the interns to the integration of the two fields. Didactic conferences attended by all interns at Griffin include a monthly session on clinical preventive service delivery and another on clinical epidemiology/evidence-based medicine. Thus, integration begins in PGY1, and completion of the internship at Griffin rather than alternative sites is preferred, although not mandatory.

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PGY2

Upon completion of PGY1 (the clinical year), residents begin the PGY2 year with two months (July and August) of clinical duties. In September of PGY2, residents begin the curriculum leading to the MPH at the Yale University School of Public Health. During the remainder of PGY2 (January to June), residents resume clinical activities. PGY2 residents are expected to participate in research meetings, research activities, and the preventive medicine seminar. In addition, the residents are encouraged to pursue clinical electives germane to both internal and preventive medicine (e.g., occupational medicine), and to identify population-based issues relevant to clinical rotations. One example of the latter exercise is using a rotation in the emergency department as an opportunity to assess the frequency of presentations by women not up-to-date with recommended mammography screening and to design a mammography referral program for the emergency department. Evaluation of the effectiveness of such a program might serve as an integration exercise for a subsequent resident or might develop into a research project. During clinical rotations in PGY2, residents meet weekly or as required with a member of the full-time faculty trained in both internal and preventive medicine to discuss, develop, and informally evaluate these integration exercises. Finally, residents in PGY2 are provided the opportunity to apply their new public health training by participating in administrative meetings at the hospital related to case management and in meetings of a group developed at Griffin to promote community health through collaborative efforts. Rotations completed in PGY2 may be applied toward the practicum if approved by the PM program director.

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PGY3

During PGY3, residents continue to fulfill clinical training requirements of the ABIM, complete the second full semester of academic instruction at the Yale School of Public Health, and begin the formal practicum phase of the PM residency. Of note, the distribution of academic semesters between PGY2 and PGY3 allows the residents to begin and complete MPH course work with a single cohort of classmates, enhancing the development of collaborations and relationships, and cultivating full acculturation to public health. The distribution also permits the residents to take one or two courses during non-academic semesters, facilitating compliance with four disparate requirements: (1) core curriculum requirements of the Yale School of Public Health; (2) divisional requirement of the Yale School of Public Health, which call for depth of training; (3) requirements of the ABPM, which call for breadth of training; and (4) program requirements, which include courses in research protocol development, occupational health, and electives related to the particular resident's career goals, chosen with faculty supervision.

Practicum in PGY3 generally includes a two-month rotation with the Connecticut Department of Public Health and a one-month rotation with a local department of public health, or vice versa. Objectives of these rotations are tailored to the interests of the particular resident, but in general include opportunities for program planning and evaluation, outbreak investigation, participation in public health surveillance, participation in research conducted by the health department, and participation in the meetings, lectures, and seminars relevant to the particular resident's activities in the health department. Additional practicum in PGY3 is derived from continued integration of preventive medicine activities such as those described above for PGY2, with clinical rotations. During any clinical rotation to be counted towards the resident's practicum, the resident is required to maintain a log documenting hours spent in didactic, clinical, and experiential aspects of prevention. Logs are reviewed by the program director and must be approved. Hours of approved practicum are applied toward the total obligation as fractions of a month in one of four categories: community health promotion/public health, clinical preventive service delivery, managed care, and research. A total of between three and five months of practicum is generally completed during PGY3, although a motivated resident could conceivably do even more by exploiting research, case management, and health promotion opportunities; the program's first graduate completed nearly six months of practicum in PGY3.

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PGY4

A resident completing minimal PGY 3 practicum requirements would have nine months of practicum, along with any remaining clinical requirements, and the MPH thesis to complete in PGY4. The PGY4 curriculum is planned by each resident in discussion with the program director during the spring of PGY3. Clinical electives are chosen by each resident in consultation with both the IM and PM program directors to redress any deficits in the resident's clinical training and optimize integration. The practicum is designed in accord with the resident's career goals and to provide competencies in the following representative subject areas: clinical practice of preventive medicine, with an emphasis on appropriate screening, preventive service delivery, clinical epidemiology, cost-effectiveness, and decision analysis; community-based health promotion, including service delivery outside the conventional clinical setting; outbreak investigation and public health surveillance; community networking; hospital-based case management; teaching preventive medicine principles to medical residents and/or medical students; provision of preventive medicine talks/lectures to community audiences; the preparation of grant applications; clinical research, including clinical trials; and health care legislation.

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Call

The call rotation for PGY1 is unaffected by the program innovations. During four months in the fall of PGY2, residents are engaged in MPH course work and are free of call. Senior resident coverage during this period is provided by the PGY3 and PGY4 residents. Similarly, during the latter half of PGY3, residents are engaged in MPH course work; coverage during this period is by PGY2 and PGY4 residents. Griffin service requirements call for four senior residents to take call each month in a one-in-four rotation. Thus, a total of 48 call rotations are required each year. At present, these are met by assigning approximately six months of call to PGY2 residents, three to four months to PGY3 residents, and the rest to PGY4 residents. With expansion of the program to four or five positions in each of PGY2 through PGY4, total call obligations will remain constant or drop slightly. Call commitments are in compliance with ACGME guidelines, and are regularly reviewed internally by the Griffin Hospital Graduate Medical Education Committee.

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Fulfillment and Tracking of Board Eligibility Criteria

Board eligibility criteria for IM include 24 months of rotations in core IM disciplines involving direct patient care responsibility; six months of clinical rotations in disciplines other than IM, again requiring direct patient care responsibility; and up to six months of clinical or non-clinical electives not requiring direct patient care. Board eligibility criteria in PM include an accredited clinical year, an MPH degree with an emphasis on breadth of study, and 12 months of practicum rotations in a variety of preventive medicine and public health disciplines. Practicum time may be credited as didactic, clinical, or experiential. The practicum at Griffin emphasizes both breadth of training and pertinence to the career goals of the particular resident. To provide consistent breadth of training, the practicum is intended to include not less than three months of clinical prevention, three months of prevention research, four months of public health/community health rotations, and two months of managed care.

To track the board eligibility of each resident, a spreadsheet has been developed that categorizes each rotation in a particular category of IM and/or PM practicum. During the course of four years of training, several rotations will be applied toward board eligibility in both disciplines, but only those that decisively fall within a pertinent category of each. Such rotations are reviewed, and must be approved, by the program directors in both IM and PM. A full month of pertinent experience is required before a month is applied in full toward board requirements in either discipline. The application of a single rotation toward eligibility requirements of both boards may require additional work hours during the month; such arrangements are discussed with the resident in advance. The majority of practicum rotations are non-clinical, and the majority of clinical rotations are not applied toward the practicum requirement.

One resident has graduated the integrated program, and another is currently in the fourth year, with all remaining rotations planned. The one graduate has already passed the IM board examination, and has over 15 months of well documented practicum rotations. Our first graduate earned the MPH degree with honors while meeting all ABPM requirements. The current fourth year resident has already met all board eligibility criteria in IM, has exceeded all MPH requirements save completion of the thesis, and is projected to graduate with 13½ months of practicum.

The distribution of rotations over the four-year period and their application toward board eligibility requirements for the program at capacity are shown in Table 1.

Table 1
Table 1
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Administration

The program is directed jointly by IM and PM faculty. IM faculty consists of a full-time director, an associate director, and a residency manager/chief resident, all of whom are board certified in IM. The PM faculty consists of a full-time director, a part-time associate director, and a full-time residency manager/chief resident, all of whom are board certified or board eligible in PM. Primary responsibility for the integration of the two programs rests at present with the director of PM, who is board certified in both IM and PM. Administrative support is provided by a residency coordinator serving both residencies. Development and oversight of resident schedules to assure compliance with all requirements of both the ABIM and ABPM are provided jointly by both program directors.

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Affiliations

The program requires an array of inter-institutional affiliations to support a diversity of clinical, academic, and practicum rotations. The IM residency at Griffin is affiliated with the Yale School of Medicine and Yale-New Haven Hospital, the Department of Geriatrics at the University of Connecticut, and Oxford Health Plans. The PM residency is affiliated with the Yale School of Public Health; the Connecticut Department of Public Health; the Departments of Public Health of the Lower Naugatuck Valley, city of Stamford, and city of New Haven; the Yale Health Plan (a staff-model HMO); Oxford Health Plans; and the Center for Community Responsive Care, Boston, MA. Affiliations with the Connecticut Peer Review Organization (now “Qualidigm”), and the Center for Science in the Public Interest are currently being finalized. An affiliation with the Yale University Center for Eating and Weight Disorders is under discussion. Aspects of training not addressed through institutional affiliation may be addressed through faculty affiliations. As an example, the chairperson for the Connecticut State Legislature Health Care Subcommittee is a member of the PM residency advisory committee, and serves as a rotation preceptor.

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Funding

Resident salaries are reimbursed in accord with current Medicare regulations. Griffin fully subsidizes the costs of the MPH degree, which approximate $20,000 per resident, all-inclusive, as of 1998. Grant applications for additional support of program expansion are in preparation. Maintenance of the program without external financial support is contingent upon resident participation in hospital-based programs to improve the quality and cost-effectiveness of care, and on programs to measure such outcomes. These activities are ongoing, and have generally been successful to date.

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Accreditations

The IM residency at Griffin was fully accredited by its RRC prior to development of the integrated program. The PM residency, established concomitantly with the integrated program, was provisionally accredited by its RRC effective July 1997; it will consider full accreditation of the PM residency following a site visit in the fall of 1999.

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Admission and Eligibility

Applicants may seek entry into the program at the PGY1 level or, space permitting, at the PGY2 level following a preliminary year in IM. Separate admission processes have been preserved for the integrated residency and the MPH program at Yale. Applicants to the program are screened and, if eligible, referred to the admission office at the Yale School of Public Health. Applications to the school of public health are evaluated on a rolling basis; admissions to the residency program are processed through the National Residency Match Program. Only those candidates admitted to the school of public health are considered for the match list.

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PROGRESS

One resident enrolled in the program as a PGY2 resident in 1995 and graduated in July 1998. A second resident began as a PGY2 resident in 1996 and is currently in the final year of training. Thereafter, through 1998, two PGY1 residents have been admitted each year. Implementation of the program at Griffin has significantly heightened competition for available positions. While Griffin historically filled its positions in IM predominantly with international graduates outside of the match, all positions were filled through the match for 1998. Both PGY1 residents in the integrated program are U.S. medical graduates. Recruitment efforts, presumably necessary only until the availability of the program is widely known, have consisted of attendance at residency fairs sponsored by the American Medical Students' Association (AMSA), a series of paid advertisements in AMSA's New Physician journal, and the posting of a program description at pertinent web sites, such as that sponsored by the American College of Preventive Medicine (ACPM). Applicants, including both U.S. medical graduates and qualified international medical graduates, generally apply to other internal medicine residencies; a much smaller group applies to other preventive medicine programs.

The program has fostered a wide range of research initiatives. In addition to internally funded data analyses, the program has been successful in attracting external funds for research. A clinical trial assessing nutrient effects on endothelial function and costing more than $150,000 is nearly complete. Residents in the program participated, under faculty supervision, in the preparation of a grant application to the Centers for Disease Control (CDC) for funds to support a prevention research center located at Griffin and directed out of both Griffin and the Yale School of Public Health. Notification of the grant award, totaling approximately $3 million over five years, was received in September 1998. The center is currently under development, and will oversee as many as ten community-based prevention studies over the next several years. Residents will participate in all activities of the center. Other grant applications are under review and in preparation. The program has been generating peer-reviewed publications at a brisk pace.

Residents in the program have presented posters at Prevention '97 and '98, winning an award for the outstanding resident poster in 1997. A poster presented by a resident in the program at the American College of Physicians Connecticut chapter scientific meeting in May 1998 won second prize out of nearly 100 posters.

Faculty and residents have worked together to enhance the value of morning report, the daily review of all admitted patients, for both residents and medical staff. Complicated or controversial cases result in an evidence-based assignment, in which the admitting resident, with the help and supervision of the PM chief resident and faculty, searches the medical literature and develops a written report for presentation to both the resident and attending staff involved. The report is posted on an “evidence-based case discussion” board accessible to the entire medical staff as well. Residents and attending physicians also jointly participate in a monthly evidence-based medicine/clinical epidemiology conference, sponsored by the PM department.

In October 1998, a hospitalist service, staffed by full-time faculty in the IM and PM programs, was created at Griffin. This service offers in-hospital coverage to the patients of community physicians. The service objectives are to enhance both the quality and cost-effectiveness of inpatient care. This program permits development of a call-from-home hospitalist rotation for senior residents. The hospitalist service will be combined with case management rotations, in which residents review charts to assess the efficiency of resource utilization, and compliance with practice guidelines and clinical pathways; contribute to efforts to expand the hospital's electronic database; and participate in disposition planning. Residents will work with quality assurance and discharge planners, as well as the attending hospitalist, to acquire refined case-management skills.

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DISCUSSION

The program described has distinct advantages over other approaches1,4,6,8,29,30 to the challenge of providing skills in population-based practice and effective preventive service delivery to primary care physicians.

First, the integrated residency allows for comprehensive, rather than rudimentary, training in clinical epidemiology, research methods, community-oriented primary care and health promotion, cost-effective practice, managed care, and other aspects of population-based health care delivery. The material is simply too expansive to be accommodated in the already-crowded curricula of medical school or established residencies. Exposure to more limited training in PM may be sufficient to produce clinicians who can adhere to guidelines and standards, but is generally insufficient to produce the leaders who can generate such standards. By combining training in IM with PM, the program becomes attractive to medical students interested in clinical practice but eager to acquire a broader array of skills, and perhaps incorporate research, health policy, teaching, public health practice, or administration into their careers. The integrated program eliminates the dilemma students may face in choosing between primary care and public health, and establishes a training model consistent with the goals of the Medicine/Public Health Initiative.31,32 Cashman and colleagues recently highlighted the potential importance of preventive medicine residency training to the Medicine/Public Health Initiative.33 The integrated residency they described provides a detailed structure to support the laudable concept of linking community-oriented health promotion and patient-directed clinical care.

The integrated program is also financially advantageous to students. While medical schools offer a variety of options to students interested in an MPH degree, including a free fifth year, or a four-year joint degree program,18 none pays students to train in public health. By deferring the MPH to residency, students both avoid the need to pursue an abbreviated degree program and earn a salary while studying. Residents in the program receive a full, graduated salary during all four years of training. To date, Griffin has been subsidizing the MPH degrees of program residents without external financial support. While external support is being sought to facilitate expansion of the program, financial self-sufficiency is potentially feasible. Salary support for residents during that portion of their training that involves the care of inpatients is available through Medicare.

Something of a programmatic quid pro quo has been established in which residents benefit educationally by participating in administrative, executive, and quality assurance meetings, and the hospital benefits as the residents develop and help implement programs designed to improve the quality and efficiency of care. This arrangement provides residents an opportunity to apply much of their newly acquired public health knowledge, enhancing their academic experience. Initiatives to date include the development of an enhanced electronic medical record; labeling inpatient charts with a projected date of discharge; development of a daily log residents provide head nurses after rounds to inform them of scheduled procedures and discharge planning; a brochure highlighting preventive services that is handed out along with emergency department discharge instructions; and the development of inpatient clinical pathways and outpatient practice algorithms. Since implementing the program, average length of stay at Griffin has declined nearly two days while readmission and patient satisfaction have remained essentially constant, although initiatives generated by the residency program account for only a portion of this trend.

The program offers additional advantages pertaining to academic, practicum, and clinical training. Residents complete more credits toward the MPH degree than would be possible in a single year and yet add only a single year onto a standard IM residency. This is possible because the academic calendar is actually only eight months long and because additional class hours are interspersed with clinical rotations. Residents may thus graduate with both depth and breadth of public health training. Similarly, the distribution of the practicum phase over two and even three years results in more than 12 months of practicum training and a greater breadth of exposures than a conventional two-year PM residency can provide. Clinical training is enhanced both because it is approached with population-based skills and because actual patient contact is increased relative to a conventional IM residency; practicum rotations devoted to clinical preventive service delivery represent additional opportunities to refine the clinical skills of residents in both in-patient and out-patient settings, beyond the core requirements of the ABIM.

Perhaps most important, the integrated program provides a more appropriate basis for a career incorporating both clinical and population-based efforts than the next best alternative, sequential residencies. Training in IM requires three years. Training in PM also requires three years, but the internship year may be applied toward both programs. Therefore, sequential training in IM and PM requires five years. Explicitly, such training requires a substantial time commitment, application and entry into two programs, and relocation as required to complete two residencies. Implicitly, such training breaks into two pieces the components of a single career embracing both clinical and population-based practice. The integrated program maintains a constant dialog between medicine and public health. When residents return to the wards following a semester of courses toward the MPH degree, clinical rotations are seen not only as exercises in the care of individual patients, but as windows to underlying population patterns of modifiable risk and to the strengths and weaknesses of the health care delivery system. Similarly, residents enter and complete the MPH program and practicum with extensive training in clinical medicine, enhancing appreciation for the complementarity of the clinical and population approaches to health care delivery. Patient encounters, and clinical dilemmas, often serve as the basis for thesis and other research projects. Residents are supervised throughout by faculty encouraging them to see the complementarity of clinical and population-based medicine; separate residencies may be more apt to emphasize disparities and competitive advantages of one versus the other.

The integrated program model is beneficial to the field of PM by drawing in highly qualified residents who might otherwise pursue exclusively clinical careers. The program is beneficial to the primary care disciplines by imparting to graduates highly valued skills and knowledge. The program is advantageous to sponsoring institutions by providing an unique attraction to highly qualified applicants; the prospect of board eligibility in both IM and PM, of acquiring an MPH degree, of obtaining the full array of skills most conducive to leadership in health care, and of being paid during the entire four-year process is a very attractive package. Our experience also suggests that the model may contribute to economies of care that partly, or even fully, compensate for the costs of the program. The program benefits residents educationally and financially, and offers them ideal career preparation for the current health care marketplace. Patients, and the general public, should benefit as knowledge of public health and preventive practice is disseminated more widely among clinicians.

There are, in addition to the considerable advantages of such a model, limitations. Only hospitals with access to accredited master's degree programs in public health could offer the program in its current form. The model described leaves unaddressed the challenging question of how much prevention and public health should be universally incorporated into medical education, and by what means. The market for graduates of such a program, while ostensibly great, has an unknown capacity. The extent to which such a model should be replicated is therefore uncertain. Whether the graduates of such programs should serve exclusively as health care leaders, or whether such training should become the new standard for primary care practitioners, is open to debate. The logistic demands of running such a program are considerable, but by no means prohibitive. In meetings of the IM and PM competency committees, curriculum committee, and the Graduate Medical Education Committee at Griffin, no significant conflict between the two integrated programs has been identified, nor has there been any report of excess work imposed on a resident. The one minor conflict discussed pertained to daytime coverage of integrated program residents attending classes at the Yale School of Public Health during clinical rotations. The issue was resolved by delaying graduation from the MPH program until year 4, and thereby extending the period available to residents for academic work. By distributing the classes over a longer period, interference with clinical obligations has been eliminated.

In summary, we have implemented an innovative residency program well suited to the current health care environment. Graduates from programs such as the one described are an important resource for more successfully integrating public health and medicine, and optimizing the delivery of clinical preventive services. Previously, such skills could be acquired only through separate, sequential residencies. The model described offers such training more efficiently, and by exploiting the complementarity of its two components, provides even more training than the sum of its parts. Replication of the model may be indicated to: (1) expand the ranks of clinicians trained for leadership roles in academia and managed care; (2) attract the most highly qualified candidates to primary care and preventive medicine; and/or (3) provide training that raises the standard of primary care. To determine whether the promise of the model is realized, studies of the outcomes of such training with respect to career development, practice patterns, and the contributions of graduates to medical practice and public health will be required.

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