Since 1963, funding appropriated by Congress under Title VII has financed the expansion and improvement of medical and dental training programs in health professions schools across the United States. However, the lasting impact of Title VII cannot be simply quantified in terms of newly constructed facilities and increased class sizes. While a legislative history of Title VII appears elsewhere in this theme issue of Academic Medicine, this article goes beyond bricks and mortar to examine the educational innovations attributed to Title VII.1 Such innovations are discussed broadly in this article, but the other articles in this theme issue highlight, in-depth, many specific examples of educational innovations made possible by Title VII funding.
Background and Overview of Innovations
Period one, 1963–1975
Although the main accomplishment of the first era of the Title VII program (1963–1975) was expansion of medical, dental, and other health professions schools, curricular innovation did emerge from this early period. Medical schools receiving Title VII funding were encouraged to experiment with interdisciplinary training models, explore the use of new educational technologies, and implement courses in substance abuse and nutrition. Of importance to the future of the Training in Primary Care Medicine and Dentistry (TPCMD) grant program, the new disciplines of physician assistants (PAs) and family medicine garnered congressional attention, with funds appropriated beginning in 1971 to establish training programs in both fields.
Period two, 1976–1991
Throughout period two of the program (1976–1991), Title VII grant funds helped finance the development of the first models of general dental residency training. These federal dollars defined primary care to include family medicine, general internal medicine, and general pediatrics and expanded training for medical students, residents, fellows, and faculty in these three primary care disciplines. Innovations occurred in ambulatory care training with a focus on community-oriented primary care (COPC) and preventive medicine, as well as ethics, distance learning, behavioral health, and the foundational elements of what is now called evidence-based medicine. During period two, federal funds also helped build the infrastructure of primary care through recruiting new faculty, expanding ambulatory training sites into new community settings, and incorporating new curriculum topics relevant to primary care separately from information taught through caring for in-hospital patients. Some of the major textbooks and curriculum resources in ambulatory medicine, now used by students and by residents in both primary and categorical training programs, emerged from these comprehensive and innovative curricula and faculty development efforts.
Faculty development programs funded under Title VII have given both full-time faculty and community preceptors new skills in office-based teaching and evaluation of students and residents. The goal was to train these faculty members to create a higher-quality experience in ambulatory training and to recruit students into generalist disciplines, thus enhancing the care of patients by these trainees once they entered clinical practice. Other disciplines, both specialty and nonspecialty, were affected as they incorporated some of the content of primary care into their clerkships (e.g., diagnosis and treatment of chest pain, asthma, or substance abuse taught in family medicine, general internal medicine, general pediatrics, obstetrics–gynecology, and emergency medicine rotations).
The impact of Title VII increased as courses in ethics, evidence-based medicine, and doctor–patient communication that had been developed originally by primary care faculty were incorporated into the general curriculum. In reality, the TPCMD grant program served not only as an engine for innovation in primary care but also for premedical and graduate medical education and PA and dental residency training. This continues today during period three as health professions training programs integrate courses in areas such as cultural competency, public health, medical professionalism, and quality improvement that were pioneered by the primary care disciplines.
Period three, 1992 to present
During the most recent period of the Title VII program (1992 to present), the focus shifted from promoting primary care training to developing curricula in areas of emerging clinical relevance or national priority, training in the care of vulnerable persons, and designing educational strategies to eliminate health disparities, often through collaborative partnerships between medicine and public health. The goal clearly was to require grantees to focus more on equipping students and residents with knowledge, attitudes, and skills essential to caring for America's underserved populations in rural and urban areas. If an innovation was proposed, such as a new curriculum on patient safety, oral health, or genetics, it was to be implemented among ethnically and racially diverse patients and those with limited or no access to medical and dental care. This often forced medical and dental schools and residency programs to create partnerships with community and migrant health centers, use the network of clinical sites created by the Area Health Education Center in their state, or expand their outreach to vulnerable populations in their own neighborhood.
Consequently, the TPCMD grant program has contributed to the rise of service learning activities in American medical and dental education. The mandates in the 1992 and 1998 Title VII reauthorization legislation, captured in the Medically Underserved Community Preference and identified vulnerable populations, reinforced the effort of PA programs, medical and dental schools, and residency training programs to provide clinical care to the poor in their school- and hospital-based clinics and neighboring homeless shelters, free clinics, and community health centers. These mandates also fostered the creation of required and elective clinical rotations focusing on disadvantaged populations, and special tracks in “rural medicine” and “underserved medicine.”
A review of funded Title VII grant applications from 2000 through 2005 demonstrates that most, if not all, of these grantees fulfilled the legislative intent of improving the training of health professionals to care for the underserved and for special, vulnerable populations that include the homeless, elderly, persons with HIV/AIDS, substance abusers, and victims of domestic violence. What becomes clear through a systematic analysis of the work of Title VII grantees is that these federal funds have helped shape the education of health professionals in ways that do not occur through specialty and subspecialty training inside the hospital or in its operating or emergency rooms. And herein may exist one of the most important reasons for continuation of the primary care medicine and dentistry grant program: Title VII has become an essential component of America's health care safety net.
Areas of innovation listed in the TPCMD grant guidance most often have had their origins in recent reports of the Advisory Committee on Training in Primary Care Medicine and Dentistry (ACTPCMD), Institute of Medicine–National Academy of Sciences (IOM), and Office of the U.S. Public Health Service Surgeon General, or in new standards of training developed by national accreditation bodies for the various health professions.1,2 Since 2000, these areas have included quality improvement, patient safety, evidence-based medicine, cultural competency, health literacy, public health, geriatrics, oral health, genetics, and medical professionalism. This article focuses on three major areas that capture much of the current work of Title VII grantees: clinical skills and practice improvement, interdisciplinary models of training and patient care, and care of vulnerable and underserved populations.
Clinical Skills and Practice Improvement
This section describes some of the work of Title VII grantees in the areas of cultural competency, genetics, oral health, and quality improvement and patient safety.
Cultural competency has been a major focus of the TPCMD grant program because it reflects the mission of the Health Resources and Services Administration (HRSA) and recommendations of the IOM and the ACTPCMD. The third report of the ACTPCMD (2003) focused solely on cultural competency and diversity of the health professions as strategies to reduce health disparities.3 The Title VII grant guidance has included cultural competency as an area of innovation since 2001. Consequently, between fiscal year (FY) 2001 and FY2005, approximately 35% of grantees included skills development in cultural competency as one of their main objectives, with many of these grantees coming under the residency training in primary care program area. As illustrated in the article by Green et al,4 this has resulted in increased skills in cultural competency among graduates of Title VII-funded residency programs when compared with residents trained in programs that did not receive these federal grants. Training methods often include readings, videos, small-group interactive discussions, OSCEs for both teaching and evaluation, and clinical experiences with multicultural patient populations. With consolidation of all six TPCMD programs under one grant guidance in 2000 (a consequence of the 1998 Title VII-reauthorizing legislation), PA training programs and dental residencies were encouraged also to develop curricula in cultural competency.1
There is little debate that the Human Genome Project will affect clinical medicine in the 21st century as information on the contributions of genetics to disease prevention, diagnosis, and treatment penetrates into patient care. HRSA awarded a major contract to the Society of Teachers of Family Medicine (STFM) in 1998 to implement a national faculty development program bringing together faculty in primary care medicine with those in medical genetics to prepare these generalists with knowledge and skills to enable them to integrate genetics into their teaching and clinical practice.5–7 In the first report of the ACTPCMD, published in 2001, members recommended that TPCMD grantees develop curricula in genetics as part of their training programs.8 Between FY2003 and FY2005, 28 grantees included genetics as one of their major objectives. In doing so, some expanded the impact of HRSA's contract to STFM when they proposed using the case-based “Genetics in Primary Care”6,7 curriculum with medical students, residents, and faculty. Others developed innovative evaluation methodologies to teach trainees how to integrate genetics into their clinical practice. A similar contract, described in the article by Glicken,9 was awarded to develop genetic competency of faculty of PA, nurse practitioner, and nurse midwifery training programs, and several grantees in the PA Training in Primary Care program included genetics in their grant objectives. The article by Altshuler et al10 in this issue illustrates well how Title VII funding helped one pediatric residency program create its initial set of OSCEs in cultural competency and then, with a subsequent grant award, expand the program to include genetic OSCEs while still addressing issues relevant to its multicultural patient population. The authors conclude that OSCEs are an effective tool both for teaching genetic information and for evaluating residents' skills in counseling patients about genetic diseases, risks, and associated conditions.10
The surgeon general's report on oral health, published in 2000, awakened the medical community to the major health impact of dental caries and the need to incorporate prevention, diagnosis, and early treatment of dental disease into generalists' clinical practice.11 Disparities in access to dental services between insured and affluent Americans compared with uninsured and vulnerable populations only magnified the problem. Poor children suffered more dental disease that would persist into adulthood and, thereby, eliminate any chance of a disease-free life. The recommendations that followed shaped the Title VII program in two major ways: (1) by increasing the number of Title VII-funded pediatric dental residencies, and (2) by promoting curricula in oral health in the other Title VII program areas. In fact, 15 Title VII grantees in FY2003–FY2005 included oral health in their grant application objectives. All of the grantees anchored these innovative curricula within broader initiatives to provide more comprehensive care to vulnerable populations. Elsewhere in this issue, Ng et al12 describe in their article how Title VII funding stimulated significant innovations in education in oral health through the creation of collaborative training programs between family medicine, pediatrics, and pediatric dentistry, all focusing on enhancing residents' skills in comprehensive care of disadvantaged children.
Quality improvement and patient safety
The IOM reports, Crossing the Quality Chasm13 and To Err is Human,14 ushered in changes in the practice of medicine as hospital administrators and health professionals in all disciplines reexamined health care delivery with a focus on improving quality and patient safety. The Accreditation Council on Graduate Medical Education took the lead and incorporated education in systems-based practice and learning—or, in other words, skills training in quality improvement and patient safety—into its general requirements for residency training.15 Congress responded to the IOM reports by increasing funding to the Agency for Health Care Research and Quality (AHRQ) to conduct research and develop programs to reduce medical errors in hospital and ambulatory settings. Similarly, HRSA incorporated quality improvement and, later, patient safety as areas of innovation, into the TPCMD grant guidance.2 Most of the curriculum work in this area funded by Title VII is being done by residency programs, with the University of Virginia having one of the most extensive initiatives. In their article in this issue, Voss and colleagues16 demonstrate how subsequent Title VII grant awards, all focusing on building a comprehensive program on teaching quality and patient safety, can change the culture within the hospital more broadly.
Interdisciplinary Models of Training and Patient Care
Generalists have long been at the frontline of patient care that demanded models of training to prepare them to work with other health professionals, such as PAs, patient educators, and psychologists. Accordingly, the Title VII legislation has promoted interdisciplinary training as far back as period one (1963–1975). More recently, grantees most often have received funding to develop interdisciplinary training models by educating trainees in public health, geriatrics, and palliative and end-of-life care, and on the chronic care model and the patient-centered medical home.17–19 This section provides an overview of these interdisciplinary training innovations, first focusing on the integration of public health into medical and dental education.
Medicine and public health.
Whereas Title VII initiatives in public health focused on COPC and preventive medicine during period two (1976–1991), there has been a more explicit effort since the mid-1990s to create collaborations between medical and dental schools with schools of public health and local and state health departments. All six TPCMD program areas have grantees that are integrating public health in one of three ways: (1) focused lectures (e.g., health disparities, bioterrorism) and modules/short courses (e.g., public health and border populations), (2) longitudinal curricula that span two to four years of training, or (3) joint-degree programs or incorporating core coursework for a masters of public health (MPH) degree into the medical and dental schools and residency curricula, with the expectation that graduates complete the advanced degree before or within a year of finishing their program. The article by Shannon20 in this issue shows how far-reaching Title VII funding can be as one osteopathic medical school revised its curriculum, focusing first on core competencies, and then adding training in public health, as part of an overall strategy to populate Maine's rural communities with well-trained generalist osteopathic physicians.
As described in more detail in the article by DeWitt and Cheng21 on pediatric fellowship programs, the most extensive collaboration between medicine and public health occurs within the TPCMD Type I faculty development program area, with nearly all grantees requiring their clinician–researcher fellows to complete an MPH during their fellowship. Those Type I fellowships that do not require an MPH degree require completion of a masters of epidemiology or masters of clinical science. These fellowship programs are being conducted by divisions of general internal medicine, divisions of general pediatrics, and departments of family medicine, with many grantees collaborating to offer training to fellows from two or three primary care disciplines. These fellowship programs have helped build and sustain the academic presence of generalist medicine within medical schools and health science centers around the country. They have raised the quality of faculty in academic generalist medicine and, thereby, contributed to the growth of these divisions and departments, despite increasing emphasis within medical schools on basic science research and specialty and subspecialty medicine. In addition, these Title VII-funded fellows and faculty have enabled divisions and departments to compete successfully for grants from AHRQ, National Institutes of Health, and the Robert Wood Johnson Foundation (RWJF). Perhaps most important, they have moved the research agenda in health disparities, quality improvement and patient safety, evidence-based medicine, and other national priorities to a place where generalist researchers can work effectively with others toward translating this science into new public policies to address the needs of disadvantaged and vulnerable populations.
Geriatrics, palliative, and end-of-life care.
Care for the elderly has been an explicit focus of the Title VII legislation since 1988, first with funding for Geriatrics Education Centers and then with inclusion of the elderly as one of five vulnerable populations. Additionally, the 2001 report of the ACTPCMD and the 2003 TPCMD grant guidance called for proposals to address specifically the need to train professionals in geriatrics to include “knowledge of the normal aging process, health promotion and disease prevention activities for the elderly, diseases and other special problems of aging individuals, including psychosocial aspects of aging.”22 Accordingly, 31 grantees were awarded funding in FY2003 to carry out such objectives. By FY2006, there were 44 TPCMD grantees that were engaged in geriatrics training representing all the disciplines and program areas, including dental residency training. The ACTPCMD also recommended in its first report that primary care clinicians develop added competence in palliative and end-of-life care.8 Again, Title VII grantees responded, with more than a dozen programs receiving funding to implement innovative curricula in this area.
Chronic care model and the patient-centered medical home.
The IOM report, Crossing the Quality Chasm,13 found numerous failures in the current approach to providing health care in this country, with recommendations that medical training and health care delivery be changed fundamentally. One strategy was adoption of the Chronic Care Model, developed by Ed Wagner, which posits that systematic improvement in six areas can combine to create a setting where informed, activated patients interact productively with a prepared, proactive practice team to bring about improved functional and clinical outcomes.17,18 These six areas are community resources and policies, health system organization, self-management support, delivery system design, decision support, and clinical information systems. While seemingly a daunting challenge, HRSA and the RWJF launched initiatives to develop such models. Recently, the leadership of family medicine, pediatrics, internal medicine, and osteopathic medicine endorsed implementation of the Patient-Centered Medical Home that will require physicians to be integrated fully as members of interdisciplinary teams in the longitudinal and comprehensive care of children, adolescents, adults, and the elderly19 (Sidebars 1 and 2).
Care of Vulnerable and Disadvantaged Populations
As one can see from the articles in this issue, especially those of Beck and colleagues23 and Hedgecock and Steyer,24 establishing programs to educate future physicians, dentists, and PAs about the care of vulnerable and disadvantaged populations has become a hallmark of the TPCMD program. In 2005, the author, then serving as chief of the Primary Care Medical Education Branch in HRSA, queried Title VII grantees on their work with the homeless as part of a government-wide initiative to document efforts to end chronic homelessness (unpublished data). The simple query asked grantees to share what they were doing in terms of didactic and clinical instruction, and it asked whether such training occurred with a specific focus on the homeless or as part of a larger initiative targeting health disparities. In response, more than 75 current grantees described their didactic and clinical efforts focused on this one vulnerable population. At the same time, there were only four grantees with specific objectives to develop curricula on care of the homeless. What became quickly obvious was that all the other 70+ grantees had established these clinical training programs with earlier grant funding and continued them after their objectives had been fulfilled. Many incorporated their homeless clinics and community outreach efforts to these persons into more comprehensive training on health disparities, service learning, public health, health advocacy, or as parts of special tracks on care of the “urban poor” or “underserved medicine.” These data reinforce the belief that TPCMD grantees continue to push medical and dental education in this country to fulfill its obligation to the public by demonstrating the health professions' commitment to care for all persons without regard to their ability to pay, their socioeconomic status, or their level of health literacy.
As noted in the fifth report of the ACTPCMD (2005), the Title VII grant program has been an engine for innovation, helping transform health professions education since the origin of the program in the 1960s.25 However, to properly evaluate Title VII, the advisory committee recommended strongly that the Office of Management and Budget and other groups focus on the role of the Title VII program on educating and strengthening primary care training, not on long-term health outcomes of populations. The advisory committee also noted more recently that the TPCMD program has moved educators to address health disparities and, thereby, meet many of the priority indicators of Healthy People 2010. All in all, the ACTPCMD fifth report, Evaluating the Impact of Title VII, Section 747 Programs, concluded that Title VII had achieved its stated objectives and that, in the future, adequate resources should be provided for program staff and grantees to conduct such evaluations.
With persistent cuts in funding, however, the future of the TPCMD grant program is uncertain. What is certain, though, is that the innovations brought forward under Title VII have had a significant impact on primary care specifically and on American medical and dental education more generally. With an impending crisis in the primary care medical and dental workforce,12,26–28 it would seem prudent to use the lever of federal funds for Title VII health professions training to achieve the next level of reform, and to continue promoting the values of professionalism across the health professions.
1 Reynolds PP. A legislative history of federal assistance for health professions training in primary care medicine and dentistry in the United States, 1963–2008. Acad. Med. 2008;83:1004–1014.
2 Program Guidance. Training in Primary Care Medicine and Dentistry. Washington, DC: U.S. Department of Health and Human Services, Bureau of Health Professions. CFDA No. 93.884.
3 Advisory Committee on Training in Primary Care Medicine and Dentistry. Training Culturally Competent Primary Care Professionals to Provide High Quality Healthcare for All Americans: The Essential Role of Title VII, Section 747, in the Elimination of Healthcare Disparities. Third Annual Report to the Secretary of the U.S. Department of Health and Human Services and to Congress. November 2003. Washington, DC: U.S. Department of Health and Human Services.
4 Green AR, Betancourt JR, Park ER, Greer JA, Donahue EJ, Weissman JS. Providing culturally competent care: Residents in HRSA Title VII funded residency programs feel better prepared. Acad. Med. 2008;83:1071–1079.
5 Davis AK, Reynolds PP, Kahn NB, et al. Title VII and the development and promotion of national initiatives in training primary care clinicians in the United States. Acad. Med. 2008;83:1021–1029.
6 Burke W, Acheson L, Botkin J, et al. Genetics in primary care: A USA faculty development initiative. Community Genet. 2002;5:138–146.
8 Advisory Committee on Training in Primary Care Medicine and Dentistry. Comprehensive Review and Recommendations: Title VII, Section 747 of the Public Health Service Act. Report to the Secretary of the U.S. Department of Health and Human Services, and Congress. November 2001. Washington, DC: U.S. Department of Health and Human Services.
9 Glicken AD. Excellence in physician assistant training through faculty development. Acad. Med. 2008;83:1107–1110.
10 Altshuler L, Kachur E, Krinshpun S, Sullivan D. Genetics objective structured clinical exams at the Maimonides Infants & Children's Hospital of Brooklyn, New York. Acad. Med. 2008;83:1088–1093.
11 United States Department of Health and Human Services. Oral Health in America: A Report of the Surgeon General. Rockville, Md: National Institute of Dental and Craniofacial Research, National Institutes of Health; 2000.
12 Ng MW, Glassman P, Crall J. The impact of Title VII on general and pediatric dental education and training. Acad. Med. 2008;83:1039–1048.
13 Quality of Health Care in America Committee. Crossing the Quality Chasm: A New Health System for the 21st Century. Washington, DC: National Academy Press; 2001.
14 Quality of Health Care in America Committee. To Err Is Human: Building a Safer Health System. Washington, DC: National Academy Press; 2000.
16 Voss JD, May NB, Schorling JB, Lyman JA, et al. Changing conversations: Teaching safety and quality in residency training. Acad. Med. 2008;83:1080–1087.
17 Wagner EH. Chronic disease management: What will it take to improve care for chronic illness? Eff Clin Pract. 1998;1:2–4.
18 Rothman AA, Wagner EH. Chronic illness management: What is the role of primary care? Ann Intern Med. 2003;138:256–261.
19 American Academy of Family Physicians; American Academy of Pediatrics; American College of Physicians; American Osteopathic Association. Joint Principles of the Patient-Centered Medical Home. March 2007. Available at: (http://www.medicalhomeinfo.org/Joint%20Statement.pdf
). Accessed August 4, 2008.
20 Shannon SC. Reflections on the impact of Title VII funding at the University of New England College of Osteopathic Medicine. Acad. Med. 2008;83:1060–1063.
21 DeWitt TG, Cheng TL. The role of Title VII funding in academic general pediatrics fellowships and leadership. Acad. Med. 2008;83:1103–1106.
22 Program Guidance FY2003. Training in Primary Care Medicine and Dentistry. Washington, DC: U.S. Department of Health and Human Services, Bureau of Health Professions. CFDA No. 93.884.
23 Beck E, Wingard DL, Zúniga ML, Heifetz R, Gilbreath S. Addressing the health needs of the underserved: A national faculty development program. Acad. Med. 2008;83:1094–1102.
24 Hedgecock J, Steyer TE. The American Medical Student Association's contributions to advancing primary care. Acad. Med. 2008;83:1057–1059.
25 Advisory Committee on Training in Primary Care Medicine and Dentistry. Evaluating the Impact of Title VII, Section 747 Programs. Fifth Annual Report to the Secretary of the U.S. Department of Health and Human Services and to Congress. November 2005. Washington, DC: U.S. Department of Health and Human Services.
28 Bodenheimer T. Primary care—Will it survive? N Engl J Med. 2006;355:861–864.