Hedgecock, Joan MSPH; Steyer, Terrence E. MD
Continuous congressional funding of the Title VII, Section 747 Training in Primary Care Medicine and Dentistry grant program (Title VII) “is the major vehicle for stimulating primary care education and training in the United States.”1 As a major national participant in medical education, the American Medical Student Association (AMSA) Foundation has received several contracts from the Bureau of Health Professions/Division of Medicine and Dentistry promoting primary care and cultural competency training among clinicians in training. In this article, we discuss the Title VII, Section 747-funded programs administered by AMSA.
Background on AMSA
Incorporated in 1962, the AMSA Foundation is the programming arm of AMSA, a national, nonprofit membership organization with 67,000 members and chapters on 163 allopathic and osteopathic campuses across the United States (AMSA Membership Database [staff-only resource], accessed June 20, 2008). AMSA addresses health professional students’ concerns related to global and domestic social and health problems. AMSA Foundation programs have offered nontraditional learning experiences to medical and other graduate-level health professional students on issues concerning underserved communities, institutional change, and the development of human potential.
Since 1970, the AMSA Foundation has actively collaborated with the U.S. Public Health Service on preparing physicians and other health providers for practice in health professional shortage areas. AMSA has a rich history of training health professionals as leaders in their communities and underserved areas and of training them to work in interdisciplinary teams through community health projects in Appalachia, migrant camps, Indian reservations, and rural areas.
AMSA Programs Supported by Title VII, Section 747 Funding
Generalist Physicians in Training
Funded in 1993 and led by a student and resident advisory group, the Generalist Physicians in Training (GPIT) Program was designed to encourage medical students to pursue careers in primary care—particularly in underserved communities. GPIT developed educational workshops and activities that focused on mentoring and educating medical students about community outreach. Medical-school-based AMSA chapters sponsored GPIT interest groups that conducted these peer educational workshops and community outreach activities. Through information dissemination, advocacy, innovative programming, and research, GPIT was committed to fostering student interest in generalism and increasing the numbers of medical school graduates entering family practice, general internal medicine, general pediatrics, and obstetrics–gynecology. “Projects in a Box” were developed under GPIT to facilitate student programming on a local level, addressing topics such as managed care and rural health. Through GPIT, AMSA also initiated the Primary Care Leadership Training Project (LTP), which was hosted by a different medical school each year to showcase their primary care curriculum and which has continued through AMSA’s most current Title VII contract. At the conclusion of the contract in October 1996, GPIT counted more than 9,000 medical student members who had expressed interest in primary care.2 AMSA also launched the Primary Care Scorecard, published in AMSA’s The New Physician magazine, comparing the production of primary care physicians by U.S. medical schools.3
Promoting, Reinforcing, and Improving Medical Education
From 1998 to 2004, AMSA collaborated with medical students, faculty, and practicing health professionals on the development and pilot testing of medical school curricula under the Promoting, Reinforcing, and Improving Medical Education (PRIME) contract. Medical schools participating in PRIME adapted a set of core competencies and a curriculum outline addressing care of underserved populations and skills in cultural competency. A total of 10 medical schools were selected through a competitive process to develop new curricula in the areas of community responsiveness and cultural competency. Through PRIME, AMSA continued the LTP launched through GPIT and produced educational materials on health promotion and health disparities made publicly available on AMSA’s Web site. The PRIME collaboration also yielded educational modules, available to health professions students and educators online, addressing disparities in health care (www.amsa.org/programs/barriers/intro.html), providing guidance on cultural competency education (www.ask.hrsa.gov/downloads/CulturalCompBHP00208.pdf), and developing skills in health promotion, such as nutrition and physical activity (www.amsa.org/pdf/PhysicalActivity.pdf).4
National Primary Care Week
Between 1999 and 2005, with funding through Title VII and the National Health Service Corps, AMSA led an interdisciplinary effort promoting primary care training and practice: National Primary Care Week (NPCW). Driven by student leadership and activism, this event took place annually on health professions training campuses throughout the country. It was designed to celebrate the contributions of various health professions disciplines that provide needed primary health care, especially to populations who lack access. Each NCPW was organized around a theme, such as interdisciplinary health care teams, health care access, and health literacy. Web materials were developed by students to help in local planning efforts and provided resources pertaining to the annual theme.5
The program began a unique relationship between AMSA and primary care professionals and organizations. On the local level, it encouraged medical students to collaborate with other primary care professionals and students, including nurses, nurse practitioners, dentists, physician assistants, social workers, and pharmacists, among others. NPCW also engaged a steering committee of national organizations, including the American Public Health Association, National Area Health Education Center Organization, Community–Campus Partnerships for Health, American Association of Colleges of Osteopathic Medicine, and Society of Teachers of Family Medicine. Although NPCW has not received outside support since 2005, its benefits continue today as AMSA encourages schools to continue to conduct an annual event to celebrate the contributions of primary care to our nation’s health.6
Leadership Seminar Series
From 2002 to 2006, AMSA managed the Leadership Seminar Series (LSS). AMSA developed a curriculum for dental and medical resident–faculty pairs to help them become public health leaders. The curriculum focused on the core competencies of public health and Healthy People 2010.7 All participants designed and completed a Healthy People 2010 project at their home institution or local community, such as designing community outreach programs to facilitate access to dental care by an underserved Hispanic population. LSS was a ground-breaking contract for AMSA because it incorporated the dentistry profession into our work and mission. It also allowed AMSA to begin the development of curricular materials geared to medical and dental students, residents, and faculty. Equally important, LSS was the first project where the curriculum could be used throughout a physician’s lifespan—from student, to resident, to attending or practicing physician. From a pool of 230 applicants, a total of 80 participants completed training through LSS during the four years. Eighty-seven percent of participants stated that LSS positively influenced their professional development and increased their awareness and involvement in public health policy.8
Achieving Diversity in Dentistry and Medicine
In 2003, after the successful PRIME Project, AMSA received another Title VII-funded contract to create the Achieving Diversity in Dentistry and Medicine (ADDM) program. Ending in 2008, this project provides funding for medical and dental schools to implement cultural competency and ethnogeriatrics curricula, and it continues support for the Primary Care LTP. It also funds two new initiatives exposing youth from diverse backgrounds to careers in primary care medicine and dentistry, with the goals of increasing health care workforce diversity and attracting medical and dental personnel to careers in community health centers. Twenty-seven medical schools benefit directly from this program, including implementation of cultural competence and ethnogeriatrics curricula at 17 of these schools.9 Examples of some of the ethnogeriatrics training initiated under the project are community-based learning opportunities for students to interact with geriatric populations in nonclinical settings, increased diversity of standardized patients, modification of geriatric-specific history and assessment protocols to address cultural background of patients, use of “seniors as teachers,” and provision of learning opportunities in student-run free clinics.
A Successful Past, an Uncertain Future
AMSA’s Title VII, Section 747-funded projects have done much toward promoting primary care professions across the United States. All of AMSA’s Title VII-funded programs exposed medical and other graduate-level health professional students to careers in primary care, and, beyond that, GPIT, NPCW, PRIME, and ADDM promoted medical students to choose residency training in primary care. Addressing the critical issues of care for the underserved and promoting public health education, NPCW and ADDM encouraged students to provide health care for underserved communities and practice in health professional shortage areas, whereas NPCW, LSS, and PRIME increased medical student, resident, and faculty skills in public health. Today’s health care professionals must also be prepared to work in interdisciplinary teams, and NPCW, ADDM, and LSS specifically addressed this goal by giving health professional students an introduction to interdisciplinary teamwork. Ultimately, all of AMSA’s Title VII, Section 747-funded programs achieved the same goal of developing new leaders in primary care, locally and nationally. Although the AMSA Foundation has facilitated these initiatives, a large part of their success results from the work of medical student leaders who were able to participate because of Title VII, Section 747 federal funds.
Despite these accomplishments, the federal budget cuts to Title VII, Section 747 in fiscal year 2006 have significantly reduced the programmatic efforts of the AMSA Foundation. The LSS project was halted 2 years early, and its full evaluation could not be conducted. Further, funding ended for the successful NPCW. ADDM is ending in 2008, bringing curriculum enhancement and AMSA’s efforts to develop new primary care leaders to a halt. Loss of these federal funds introduces challenges to continuing AMSA’s innovative approaches to encouraging students to enter primary care, to care for underserved and disadvantaged populations, to learn as interdisciplinary team members, and to assume leadership roles in the health care arena. Further loss of Title VII funds would inhibit AMSA’s ability to design and adopt curricula to meet the needs of future health professionals regarding the new models of patient care, such as the patient-centered medical home and the integration of continuous quality improvement into everyday practice. Ultimately, the lack of funding for training the next generation of the primary health care workforce will lead to decreased quality of care and poorer health outcomes for our nation, especially the underserved.
Activities described in this paper were supported with Title VII funding through the following American Medical Student Association Foundation projects: Achieving Diversity in Dentistry and Medicine, contract no. 230-03-0015; Leadership Seminar Series, contract no. 230-02-0006; National Primary Care Week, purchase order no. 99-0271 (P), 00-0250 (P), 01-0244 (P), 02-0323 (P), 03-0257 (P), 04-S230-0103 (P), 05-12120 (P), and 05-12122 (P)—jointly funded with Division of National Health Service Corps; Promoting, Reinforcing, and Improving Medical Education, contract no. 230-99-0001; and Generalist Physicians in Training Program, purchase order no. HRSA 93-14 (P), contract no. 240-94-0013, and contract no. 240-96-0028.
1 Advisory Committee on Training in Primary Care Medicine and Dentistry. First Annual Report to Congress: Comprehensive Review and Recommendations: Title VII, Section 747 of the Public Health Service Act. Washington, DC: U.S. Department of Health and Human Services, Health Resources and Services Administration; 2001.
2 American Medical Student Association Foundation. Increasing the Number of Medical Students Selecting Generalist Physician Careers Final Report [unpublished]. Reston, Va: American Medical Student Association Foundation; 1996. DHHS/HRSA Contract No. 240-94-0013.
3 Ahtaridis S. The AMSA Foundation’s seventh annual primary care scorecard. New Physician. 2002;51:3.
4 American Medical Student Association Foundation. Promoting, Reinforcing, and Improving Medical Education Final Report [unpublished]. Reston, Va: American Medical Student Association Foundation; 2003. DHHS/HRSA Contract No. 230-99-0001.
5 Advisory Committee on Training in Primary Care Medicine and Dentistry. Preparing Primary Healthcare Providers to Meet America’s Future Healthcare Needs: The Critical Role of Title VII, Section 747, Fourth Annual Report to the Secretary of the U.S. Department of Health and Human Services and to Congress, November 2004. Washington, DC: U.S. Department of Health and Human Services, Health Resources and Services Administration; 2005.
6 American Medical Student Association Foundation. National Primary Care Week Final Report [unpublished]. Reston, Va: American Medical Student Association Foundation; 2006. DHHS/HRSA Purchase Order No. 05-S230-0345.
8 Duncan RP, Porter CK. Leadership Seminar Series: Evaluation Report [unpublished]. Gainesville, Fla: Department of Health Services Research, Management and Policy, University of Florida; August 2006. DHHS/HRSA Contract No. 230-02-0006.
9 American Medical Student Association Foundation. Achieving Diversity in Dentistry and Medicine Annual Report [unpublished]. Reston, Va: American Medical Student Association Foundation; September 2007. DHHS/HRSA Contract No. 230-03-0015.