Shannon, Stephen C. DO, MA, MPH
Soon after assuming the position as dean of the University of New England College of Osteopathic Medicine (UNECOM) in 1995, I learned the favorite clinical experience of our students was their rural primary care clerkship. This clinical rotation consisted of a four-week assignment to live in a rural Maine community and work with a primary care physician. These clinical faculty members were family or internal medicine physicians practicing in solo, small-group, or community health clinics in areas of the state where, frequently, they were the only sources of medical care to their communities. The positive experience of these medical students was good, I thought. In fact, it was congruent with the mission of the school which, like many osteopathic medical schools, was and is to produce primary care physicians for rural and underserved populations. So, having our students say they valued those experiences when they were forced to spend many hours away from classmates, family, and common items of modern life such as movie theaters, malls, and bookstores, made me feel like we were accomplishing something of value to them and to the care of underserved patients, perhaps even to health care in America. These highly rated Area Health Education Center (AHEC) rural medical rotations introduced me to the impact of Title VII grants, which have played such an important role in the development of the UNECOM. And, I believe that the impact of Title VII grants at UNECOM provides a lesson about the role that such programs can play in the current era of growth in allopathic and osteopathic schools in the United States.1–3
It is well known that our country faces a critical and long-standing physician workforce shortage in rural America. Although approximately 20% of the population in the United States lives in rural areas (including 20% of the elderly population), only about 9% of physicians practice in rural locations.4–6 In addition, there is increasing recognition of current and projected primary care physician shortages in general.7–9 Osteopathic medicine has traditionally placed special emphasis on training primary care physicians, and, until recently, about two thirds of graduates have pursued primary care graduate medical education and practice10 (there is a downward trend in the percentage of osteopathic medical school graduates choosing primary care specialties11). In addition, many schools target rural practice in their mission, with some version of “training primary care osteopathic physicians for underserved areas” a common refrain in the mission statements of most osteopathic medical colleges. This is consistent with the existence of many schools in rural areas. And, recently developed osteopathic medical colleges, such as those located in Pikeville, Kentucky, Blacksburg, Virginia, Yakima, Washington, and Harrogate, Tennessee, were founded with missions that continue this tradition.12 Nationally, 7% of practicing physicians are osteopathic physicians (doctors of osteopathic medicine, or DOs), and about half of all DOs practice family medicine. But, whereas only 9% of all U.S. physicians practice in rural areas, 17.4% of DOs practice there,13 15% of family practice DOs practice there,14 and 22% of physicians practicing in federally designated medically underserved areas are DOs.15
UNECOM's Commitment to Rural and Underserved Care
UNECOM was founded in 1978 by the New England Osteopathic Foundation explicitly to provide osteopathic physicians for rural and underserved New England. To pursue this mission, UNECOM needed to develop a primary-care-oriented, on-campus curriculum and associated clinical training system. As a tuition-funded institution (approximately 90% of revenues came from tuition), it relied on Title VII support for the development of key programs to implement its mission in its formative years. In subsequent years, this funding enabled the timely development of essential programs and realistic fiscal planning for institutionalization of programs after grant funding.
UNECOM's use of Title VII programs began in 1984. Early support provided the young institution with the resources to establish its Department of Family Medicine and develop its primary care focus. Subsequent funding helped the school define geriatrics as an additional center of excellence around which to build its academic and clinical programs.
The initial commitment to rural primary care was greatly enhanced by the development of the UNECOM AHEC program (which has been continuously funded since 1985). The popular rural medical rotations were created within the UNECOM AHEC, which had quickly become a very important part of the school's clinical infrastructure. Rural clinical experiences required housing, coordination, curriculum, clinical faculty orientation and development, and a variety of other types of support to make them successful. This system worked because of the juxtaposition of UNECOM's mission with the AHEC system and several additional Title VII training grants, which played a large role in the development of that infrastructure. As a result, rural, community-based preceptor sites and clinical faculty expanded, development programs were implemented, and, with additional resources from a National Library of Medicine grant, Internet technology was provided to rural preceptors' offices to facilitate faculty and student access to medical resources and curricula. Each UNECOM graduate thus experienced what practicing primary care medicine in rural Maine is like.
Title VII support also enabled the addition of a center of excellence in geriatrics to UNECOM's primary care focus. In 1998, the Division on Aging was established within the Department of Family Medicine with the assistance of two, three-year cycles of funding. UNECOM's AHEC Program and the Harvard Geriatric Education Center (GEC) collaborated for six years, from 1997 to 2003, to develop a capacity for geriatric training outreach in Maine, which led to the establishment of a UNECOM GEC in 2003 to serve the state.
Curriculum Review and Updates: Competency-Based Goals
In 1995, the UNECOM faculty undertook a review of the entire medical school curriculum to ascertain its relevance and cohesion as it related to both the school's mission and the changing environment of medical practice and implications of innovations in medical education. The review included an examination of the ultimate question of whether it was producing competent osteopathic physicians. A two-year process ensued in which residency program directors, faculty, and administrators reviewed the strengths and weaknesses of the curriculum. An analysis of alumni specialty and practice choices, coupled with input from recent graduates (still in residency training), practicing alumni, and current students, provided further assessment as to the existing curriculum. External consultants provided critical insight into emerging trends in competency-based medical education. And, an assessment of the established curriculum against common clinical encounters of practicing primary care physicians was made. This process resulted in a competency-based statement to guide its educational process across all four years (see List 1).16 The review identified a number of necessary changes in existing curriculum as well as methodologies; however, because UNECOM is a largely tuition-funded school, significant financial resources for major educational reform were lacking.
There were a variety of areas of the curriculum identified as priorities to address the newly identified, competency-based goals. One key area was community and population-based health taught via a curriculum integrated throughout the preclinical and clinical years. The school successfully sought and received a Title VII grant award (#D15PE80110, 1997–2000, $410,354) to develop its community and behavioral health curriculum, and it used that funding to
* increase the number of faculty in epidemiology, biostatistics, and population health;
* develop an integrated behavioral health curriculum across preclinical and clinical training years;
* implement on-campus and off-campus faculty development programs to assist faculty to implement new curriculum themes in these areas; and
* expand the rural community-based primary care curriculum to include a population-health-based component.
Additionally, with this funding a framework was developed to provide joint degree opportunities for medical students in the area of community and public health. Ultimately, a certificate in public health program was implemented that articulated with the Masters in Public Health (MPH) program at the University of New Hampshire. This collaboration subsequently evolved into a full-fledged MPH degree offered to medical students and other health professions students at the University of New England. The funding also enhanced the osteopathic manipulative medicine (OMM)* competency in the curriculum.17 It supported the first training grant collaboration between the Family Medicine and Osteopathic Manipulative Medicine Departments and enabled the establishment of college-coordinated OMM clinical training for third-year students.
Title VII and the Curriculum Changes
A number of Title VII programs were also instrumental in these years to the curriculum changes and the primary care and geriatrics focus of the curriculum. In addition to the establishment of the UNECOM GEC, the following programs or emphases were developed:
* Physician Faculty Development in Primary Care. This program was used extensively to develop community-based clinical faculty to implement clinical education in the rural clinical training experience (#D15HP51014, 1991–1997, $414,439).
* Academic Units in Primary Care. This grant expanded the primary care training infrastructure by establishing the Department of Pediatrics (#D12HP00061, 2000–2005, $907,200). (Before this grant, all pediatrics lectures and clerkships were conducted by adjunct, community-based faculty. The grant established an academic department with full-time faculty.)
* Predoctoral Training in Primary Care. This program refined student clinical evaluation by establishing a formal objective structured clinical evaluation (OSCE) program (#D16HP00098, 2001–2004, $497,365). (Before this grant, UNECOM had used the resources of the University of Massachusetts Medical Center's Standardized Patient/Evaluation Center for evaluating first- and second-year student clinical skill development. This grant established an evaluation center, staff, and standardized patient recruitment and training system and expanded the OSCE program to all four years.)
* Residency Training in Primary Care. This program supported the implementation of an evidence-based practice and research training program for UNECOM's family medicine residency program (#D22HP00337, 2002–2005, $347,324).
All of these Title VII-supported programs played a major role in establishing the infrastructure and curriculum that supported the roughly 115 medical students in each year of UNECOM's four-year curriculum. Although each of these grants was of limited duration, the college institutionalized all these programs after the grants ended by self-funding and reorganization of departments and personnel.
UNECOM Graduates in Practice
One test of the effectiveness of the programs is the extent to which UNECOM graduates pursue primary care specialties and practice. UNECOM graduates make up 9% of Maine physicians, 15% of Maine primary care physicians, and 24% of Maine physicians serving in rural areas. Of the 310 UNECOM graduates practicing in Maine, 68% are primary care physicians, as opposed to 32% of MDs and 44% of non-UNECOM graduate DOs. In the six New England states, 69% of UNECOM's 723 graduates are practicing in primary care. If one looks at a more recent cohort of 662 UNECOM graduates who have been out of residency training for at least two years (1996–2002), 71% are practicing in primary care, with 17% serving in medically underserved areas (personal communication: analysis by Ann Peton, National Center for the Analysis of Health Care Data, Edward Via Virginia College of Osteopathic Medicine, using the UNECOM Alumni Data Base [May 2008], AOA Master File [February 2008], and Composite Physician Data from New England State Medical Licensing Boards [February 2008]).
In a real sense, UNECOM can be viewed as an example of how Title VII programs can play a significant role in the development of a medical school whose central focus is primary care and serving underserved communities. The availability of the funding helped this young institution refine its vision and mission as a result of the federal imperatives surrounding primary health care. The funding opportunities induced UNECOM's faculty to pursue support to enhance the curriculum and further develop the college's resources. The process of reviewing the requests for proposals, assembling key faculty, staff, and community partners to evaluate these opportunities, assessing the college's programs against the federal priorities, and creating applications for those programs further developed the skills of all involved. And, it provided an additional measure of evaluation of the existing curriculum and infrastructure in comparison with changes that the college desired. Successfully competing for these funds helped the institution jump-start programs with start-up federal funding, expand faculty, access educational innovation by networking with other grantees across the nation, and expand faculty grant-making knowledge and skills via federal technical assistance and grant review processes.
The long-term impact of Title VII funding at UNECOM may have implications for other medical schools that wish to pursue a mission in line with funding priorities. Medical schools that seek to innovate in areas that align with federally designated goals (as evidenced in Title VII program funding priorities) can use such support to implement changes and institutionalize these innovations over time. Transformations resulting from grants that fund curriculum innovations, faculty development, and other substantive medical education program elements can create momentum and establish changes that become an accepted, expected, and institutionalized aspect of the educational experience. This may be particularly applicable in medical schools that have missions congruent with funding priorities, are developing new curricula, are expanding or reorganizing faculty, and/or are resource challenged. These types of innovations may be especially important in the current era of physician workforce shortage forecasts, a growing number and size of allopathic and osteopathic medical schools in the United States, and a downturn in the interest of graduates in pursuing primary care specialties.18–21
During key formative periods, Title VII served an important role in the development of UNECOM as a young institution, a role that has had a ripple effect beyond its initial funded purpose. The programs created at that time have enabled the school to pursue its mission. At the same time, they also provide resources to assist the institution in offering its students a clear pathway to choosing a primary care training track at a time when trends toward non-primary-care specialty training and practice are increasingly evident.
The author would like to acknowledge Shirley Weaver, PhD, for assistance with this article. Dr. Weaver was UNECOM AHEC director and assistant dean until 2002.
4 Rabinowitz HK, Diamond JJ, Markham FW, Paynter NP. Critical factors for designing programs to increase the supply and retention of rural primary care physicians. JAMA. 2001;286:1041–1048.
5 Council on Graduate Medical Education. Physician Distribution and Health Care Challenges in Rural and Inner-City Areas, Tenth Report. Rockville, Md: U.S. Department of Health and Human Services; 1998.
6 Rogers CC. The older population in 21st century rural America. Rural America Fall 2002;17:2–10.
13 Distribution of Osteopathic Physicians. Chicago, Ill: American Osteopathic Association; February 2006.
14 3,957 Family Practice Osteopathic Physicians Practicing in Rural America. Chicago, Ill: American Osteopathic Association; April 2006.
15 National Distribution of Osteopathic Physicians Relative to Medically Underserved Areas (MUA). Chicago, Ill: American Osteopathic Association; March 2006.
17 American Association of Colleges of Osteopathic Medicine. Overview of the four year curriculum. In: Osteopathic Medical College Information Book. Chevy Chase, Md: American Association of Colleges of Osteopathic Medicine; 2007:16.
18 Council on Graduate Medical Education. Physician Workforce Policy Guidelines for the U.S. for 2000–2020. Rockville, Md: U.S. Department of Health and Human Services; 2005.
20 Cooper B. It's time to address the problem of physician shortages. Ann Surg. 2007;246:527–534.
21 Bodenheimer T. Crisis in primary care. N Engl J Med. 2006;355:861–864.
* Osteopathic manipulative medicine (OMM) is an aspect of osteopathic medical education that distinguishes it from allopathic (MD) medical education. OMM education usually occurs through yearlong first- and second-year theoretical and skills courses and subsequent clinical experiences designed to teach students the underlying principles and techniques needed for diagnosing and treating patients with specific conditions. OMM education is in addition to, and integrated with, medical training on current and emerging theory and methods of medical diagnosis and treatment. Cited Here...