Davis, Ardis K. MSW; Reynolds, P Preston MD, PhD; Kahn, Norman B. Jr MD; Sherwood, Roger A. CAE; Pascoe, John M. MD, MPH; Goroll, Allan H. MD; Wilson, Modena E.H. MD; DeWitt, Thomas G. MD; Rich, Eugene C. MD
The Title VII, Section 747 (Title VII) legislation, which authorizes the Training in Primary Care Medicine and Dentistry grant program, provides statutory authority to the Health Resources and Services Administration (HRSA) to award contracts and cooperative agreements to professional organizations and institutions to conduct studies and to develop national programs consistent with the legislative focus of enhancing the quality of primary care training in the United States. During the past two decades, these contracts have influenced generalist medicine through three mechanisms: (1) building collaboration among the primary care disciplines and between primary care and specialty medicine, (2) strengthening primary care generally through national initiatives designed to develop and implement new models of primary care training, and (3) enhancing the quality of primary care training in specific disease areas determined to be of national importance, especially substance abuse and genetics. In addition, focusing attention on the learning of core generalist competencies has enhanced the general medical education of all medical students and residents.
Since 1988, HRSA has issued more than 35 contracts and cooperative agreements with Title VII federal funds, most often to national organizations promoting the training of physician assistants and medical students and representing the primary care disciplines of family medicine, general internal medicine, and general pediatrics. In this article, we describe the impact of the largest Title VII contracts awarded to national primary care organizations. We focus specifically on faculty development and predoctoral training because these are two of the six program areas within the Training in Primary Care Medicine and Dentistry grant program from which HRSA draws these dollars. Although we will not discuss all of the more than 35 contracts, Appendix 1 provides highlights of the contracting organizations discussed in this article, their projects, and relevant publications. Please contact the corresponding author for a complete list of the contracts.
The political and policy landscape of the two decades during which these organizations held contracts varied quite dramatically. Policy support for primary care was very strong during the first decade, from approximately 1988 to 1998, as a means of improving both access to and the cost-effectiveness of health care. With the backlash against managed care in the late 1990s and the attendant public interest in direct access to specialized services, this support declined starting in the late 1990s and continuing into the new millennium. With this change in landscape, HRSA's strategies moved from producing primary care physicians toward attracting graduates for practice in underserved areas, with specific attention to special populations at increased risk of adverse health outcomes or limited access to care. All of these influences impacted the specific expectations that HRSA had for the various contracts we describe in this article.
Building Collaboration in Primary Care
The Interdisciplinary Generalist Curriculum Project
In 1988, organizations that promoted primary care formed the Primary Care Organizations Consortium (PCOC) to address the perceived critical need for more generalists and the declining interest in generalist careers among medical students. In 1992, members of PCOC authored an article describing innovations for early medical education that might have a positive impact on medical students' selection of primary care careers.1 PCOC's model included a curriculum explicitly focused on generalist knowledge and skills. Central to PCOC's thesis was the idea that students need generalist training before the traditional clerkships and that generalist physicians should conduct this training. PCOC leaders consulted with officials in the Division of Medicine and Dentistry within the Bureau of Health Professions at HRSA about the feasibility of testing its model. HRSA determined that a medical education demonstration project, funded through a contract procurement process, would allow the government and PCOC to study the outcomes and then implement successful elements on a wider scale through a grant process.2
The Interdisciplinary Generalist Curriculum (IGC) Project was the demonstration project created in response to PCOC's recommendations about reshaping the early, preclerkship years of medical education.3,4 The IGC Project also represented the first time HRSA invited the three primary care disciplines of family medicine, general internal medicine, and general pediatrics to respond collaboratively to a federal funding opportunity.2
To foster collaboration among the primary care disciplines nationally, explicit in the seven-year IGC Project contract (1993–2000) was the establishment of an executive steering committee and an advisory committee—both composed of senior educators in family medicine, general internal medicine, and general pediatrics. The contract required that demonstration project schools, selected through competitive processes over two funding cycles (See List 1), establish similar steering committees within their own institutions. These demonstration project school steering committees were also required to include faculty in family medicine, general internal medicine, and general pediatrics who would work together in the development and implementation of a model curriculum focused on ambulatory training.
IGC demonstration school faculty funded through these two funding cycles (1994–1997, 1995–1998) participated in significant collaborative activities both nationally, with the executive and advisory committees, and locally. Although the contract specified only that collaboration occur among the three primary care disciplines, many of the demonstration schools experienced even broader collaboration, especially with faculty from the basic sciences, because the model curriculum required that clinical experiences begin during the first two years of basic science education. For example, at one demonstration school, the inclusion of a basic scientist from pharmacology in the core IGC group contributed to increased engagement between the clinical and basic sciences in the first two years.5
After the IGC Project, PCOC continued collaborative generalist efforts through workgroups. Title VII funds supported two workgroup conferences: “Building Primary Care Research Capacities: Strategies for the 21st Century” (May 1998) and a conference concerning the added value of interdisciplinary education from an evidence-based perspective in June 2001.
The Undergraduate Medical Education for the 21st Century Project
The Undergraduate Medical Education for the 21st Century (UME-21) Project, a five-year contract (1997–2002) which followed the IGC Project, focused on the clerkship years of the medical school curriculum.6 Its major goals were (1) to better prepare medical students to provide quality care to patients in an integrated health care system by stimulating collaboration between medical schools and managed care organizations, (2) to demonstrate effective interdisciplinary primary care teaching in ambulatory and community-based settings, with an emphasis on providing services to vulnerable, underserved populations, and (3) to teach concepts of population health to future practitioners while maintaining a commitment to the care of the individual.
Through leadership provided by PCOC, the UME-21 Project again brought together the three primary care disciplines of family medicine, general internal medicine, and general pediatrics, but this time it also engaged them in new partnerships with managed care organizations and integrated health care systems. Eight medical schools (List 1) were selected through a competitive application process as partner schools and, as such, were required to implement extensive curricular revisions in nine content areas, including health systems finance and practice of evidence-based medicine. Ten associate partner schools (List 1) received funds to develop more focused educational programs in at least one content area. Almost all of the curricular innovations and educational programs of the UME-21 Project occurred during the core clinical clerkships of the three primary care disciplines and involved integration across family medicine, general internal medicine, and general pediatrics.
Most significantly, UME-21 broadened the scope of collaboration. More than 50 external partners became integral to the planning and implementation of the UME-21 Project. These 50 partners included managed care organizations, multispecialty group practices, physician-hospital organizations, area health education centers, community health centers, and local health departments.7 Sharing curricular innovations of this project went beyond the partner and associate partner schools. For example, at each of the UME-21 Project annual meetings, about half of the registered participants were from non-UME-21 schools.
National generalist curricula contracts
Multidisciplinary collaborations further enhanced innovations in generalist medical education after the IGC and UME-21 Projects. The most significant of these collaborative efforts was the preclinical Collaborative Curriculum Project (CCP), one of the components of the larger and concurrent Family Medicine Curriculum Resource (FMCR) Project (2000–2004).
As part of this larger curriculum resource project aimed at family medicine, HRSA tasked the Society of Teachers of Family Medicine, the contractor, to subcontract specifically with internal medicine and pediatric organizations to define competencies for all students entering clinical clerkships, regardless of their anticipated career choices. The CCP built on earlier (1990s), separate initiatives within general internal medicine and general pediatrics to design clinical curricula for their respective disciplines that moved internal medicine and pediatrics toward a model of ambulatory care education for medical students. The CCP developed essential clinical competencies that all students should have by the time they enter their third year.8 These competencies are measurable behaviorally and are organized into the domains for residency competencies used by the Accreditation Council for Graduate Medical Education (ACGME).9 For example, one specific CCP competency tied to the Practice-Based Learning and Improvement competency of the ACGME is that students should be able to appraise and assimilate scientific evidence for improvement of patient-care practice.
Genetics in Primary Care Initiative Project for primary care faculty
The Genetics in Primary Care (GPC) Project continued the collaboration among family medicine, general internal medicine, and general pediatrics, but this time it also included collaboration between primary care and medical genetics. HRSA, the Agency for Health Care Research and Quality, and The National Human Genome Research Institute, a division of the National Institutes of Health, all provided funding for this five-year (1998–2003) contract. The contract called for the establishment of executive and advisory committees both composed of senior educators in family medicine, general internal medicine, and general pediatrics as well as experts in faculty development, program evaluation, and medical genetics.
Through a competitive grant application process, 20 institutions (List 1) were selected to form interdisciplinary teams of faculty representing family medicine, general internal medicine, general pediatrics, and medical genetics. Collaboration among members of these teams of generalists and medical geneticists was essential in (1) designing the model GPC curriculum, (2) implementing national train-the-trainer faculty development sessions on how to teach the curriculum, (3) implementing medical genetics education programs locally at the medical schools and in the community, and (4) addressing sensitive issues such as the social context of patients and families, the value placed on cultural diversity and cultural competency, and respect for patients' preferences.10
A key experience for most GPC Project teams was the enhancement of collaboration through mutual recognition of the contributions, cultures, and perspectives of the primary care and medical genetics communities. For example, geneticists often communicate all relevant information, whereas primary care clinicians use staged “anticipatory guidance” to help patients grasp new and unfamiliar subjects, such as the nuances of genetic predictability. Primary care physicians talk about taking a “family history,” whereas medical geneticists reinforce the value—even the necessity—of taking a three-generation “pedigree,” in order for clinicians to better diagnose, and then guide patients through, the enfolding genetic influences on disease and disease expression.
The participants came to describe these different, but complementary, perspectives as seeing “genetics through a primary care lens” and “primary care through a genetics lens.” Such perspectives enabled GPC teams to collaborate when they otherwise might have judged and rejected each other's views. Evidence of local collaboration was a component of the site visit evaluation for each team. Within the 20 teams, all of whom met the requirement to collaborate, 14 (70%) demonstrated collaboration among the primary care faculty members, 13 (65%) among the primary care and genetics members, and 15 (75%) among the GPC members and the institution's leadership; for example, in one school, the dean was a geneticist who was very supportive to the GPC team. Evaluation data also demonstrated significant improvement of generalist participants' knowledge and skills in teaching medical genetics in the clinic or on the wards.11
HRSA first instituted collaboration as a contract requirement in the IGC Project and then came to view this collaboration as so successful2 that it eventually required collaboration of many contracts that followed. The requirement of collaboration among primary care disciplines, which broadened to include medical specialties in the years after the IGC and UME-21 Projects, paved the way for much national collaboration which would not have likely occurred without HRSA's insistence. The subsequent PCOC workgroup activity, the multidisciplinary faculty development programs, the specific genetics tools developed by interdisciplinary GPC workgroups for use in primary care settings (see below), and the increased numbers of multidisciplinary grants all reflect that collaboration.
Strengthening Primary Care Training Through New Models and National Curricula
New models of primary care medical education: The IGC and UME-21 Projects
The IGC Project (described above), originally designed as a demonstration project to implement a specific training model, helped create a generalist culture at the 10 demonstration schools (see List 1). Approximately 7,000 students in these 10 schools experienced this new model of ambulatory training between 1993 and 2000. The impact of these curricular innovations on medical students at the IGC schools was immediate, as they saw patients early and continuously as part of their medical education.12 The entire academic medicine community—not just those in primary care—learned important lessons about the use of community-based faculty to help teach students in ambulatory settings.13 In summary, beyond the simple impact on the curricula at the 10 demonstration schools, the IGC Project stimulated innovation in the first two years of medical education, fostered the emergence of generalist leaders, promoted significant dissemination of new training models, and suggested future directions for reform of medical education in this country. Examples of these broader impacts are the development of specific recommendations for recruitment and retention of community faculty, documented movement of generalist IGC faculty into more centralized leadership roles within their institutions, and lessons learned about how to make interdisciplinary collaboration work as an aid to support reform in other areas of medical education. The experience of the IGC Project is described in a supplement to Academic Medicine from April 2001.14
Focusing on the clerkship years of medical student education, the UME-21 Project (described above) introduced new clinical experiences with managed care organizations as well as new curricula into the eight partner schools. Some of the new curricular areas introduced across partner and associate partner schools included
* health systems finance, economics, organization, and delivery,
* practice of evidence-based medicine,
* effective patient–provider relationships and communication skills,
* quality measurement and improvement,
* systems-based care,
* medical informatics, and
* wellness and prevention.
Other more focused innovations included interdisciplinary core clerkships, managed care mini-practicums, small-group seminars on ethics, professionalism, and doctor–patient communication, and courses on quality improvement and cost-effective care.7 The experience of the UME-21 Project is described in a supplement to Family Medicine from January 2004.15
National faculty development and curricula in family medicine
Family Medicine Curriculum Resource Project.
In the early 1990s, HRSA-funded work supported new guidelines for the family medicine clerkship with the aim of attaining an optimal ambulatory experience in family medicine.16 By the beginning of the new millennium, HRSA recognized a need to focus on several specific areas to enhance the education of future medical students. With four years of funding beginning in 2000, the FMCR Project produced a multipart curriculum resource aimed at (1) defining prerequisites for third-year clerkships for all students through the CCP (described above), (2) developing new content areas for the family medicine clerkship, (3) implementing postclerkship preparation for residency training, and (4) detailing specific topical areas spanning the four-year medical student curriculum. The experience of the FMCR Project is described in a supplement to Family Medicine.17
HRSA staff believed the educational continuum should address certain disease topics and, thus, incorporated specific topics into the contract requirements for the FMCR Project. These topics included end-of-life and palliative care, geriatrics, genetics, the objectives of Healthy People 2010, informatics, oral health, substance abuse, and mental health. For each, experts developed a curriculum resource for medical school faculty that outlined recommended competencies for students across the four-year continuum of medical school education, with suggested educational strategies and assessment methods.18 This resource is now available through the Society of Teachers of Family Medicine's Family Medicine Digital Resource Library (http://www.fmdrl.org).19 A critical feature of this resource is its alliance with competencies for residency training as defined by the ACGME.9 This framework thus provides a continuum across medical school education and residency training.18 In addition, others have described how this resource can be used for faculty development.20
Midway through the FMCR Project, in 2002, seven family medicine organizations initiated the Future of Family Medicine Project, which offered a blueprint for improved, patient-focused care in the 21st century. The project's final report, published as a supplement to the Annals of Family Medicine,21 laid out 10 strategic initiatives aimed at strengthening the discipline of family medicine. The HRSA funded the work of one of the task forces through a subcontract to the FMCR contract. Recommendations from this task force for training future family physicians centered around the importance of grounding their education in evidence-based medicine relevant to the care of the whole person in a relationship and community context,22 a curriculum area emphasized in the Title VII residency training in primary care grant program.
Faculty Futures Initiative.
In 1996, HRSA funded the five-year Faculty Futures Initiative (FFI) to develop a strategic plan for faculty development in family medicine. An FFI focus-group study identified needs for future faculty development in family medicine. The group emphasized Web-based delivery methods and preceptor needs, such as bringing faculty development directly to preceptors in their own settings.23 A panel of national experts serving on the FFI Advisory Committee developed, and another external panel validated, a set of competencies and time allocations required for success in various faculty roles within family medicine.24 These competencies (e.g., ability to identify a learner's needs) are useful for both designing overall faculty development programs within institutions and helping individual faculty define their own skills and needs. A 2001 study examining the need for faculty in family medicine demonstrated that despite a decrease in the number of available positions for family medicine faculty, 600 open faculty positions remained, with additional new positions projected in the coming three years.25 A second study examined underrepresented minority faculty in family medicine departments and concluded that academic rankings for these faculty were below those for both minority medical school faculty and family medicine faculty.26 The FFI also conducted a pilot study of accreditation guidelines for fellowships for family medicine faculty; the FFI reported recommendations for streamlining the accreditation process, developing guidelines for probationary status, and considering alternatives to accreditation, such as peer review.27
Preceptor Education Project.
Through a grant from the American Academy of Family Physicians, the Society of Teachers of Family Medicine (STFM) developed the Preceptor Education Project (PEP) in 1992, which is a series of modules designed to provide faculty development activities for family medicine preceptors who teach medical students and residents in their offices. In 1999, as part of the HRSA-funded FFI contract (described above), STFM updated PEP materials and developed new modules, “PEP2.” This resource has proven effective in enhancing the experience of both the preceptor and learner.
PEP facilitator guides are available to family medicine departments whose faculty wish to teach the modules, and those receiving instruction receive a participant's workbook. The guide and workbook have been among the most requested of STFM's publications, and family medicine departments use them extensively to provide faculty development for their preceptors. Additionally, family physicians engaged in medical education in other countries have used the materials as a base for providing faculty development in those countries.
National curricula and faculty development in general internal medicine and general pediatrics
Internal medicine core clerkship curriculum reform and guide.
As part of a comprehensive effort to restructure undergraduate medical education in 1993, HRSA awarded the Society of General Internal Medicine (SGIM), working in collaboration with the Clerkship Directors in Internal Medicine (CDIM), a contract to develop a new curriculum for the internal medicine third-year clerkship. This five-year contract called for a core working group of leading internal medicine faculty with support from a larger advisory committee made up of representatives from academic medicine, family medicine, general pediatrics, and other specialties. The group specified a set of core generalist competencies that it felt were central to the general medical education of all students and recommended that at least one third of clerkship time be devoted to ambulatory care. It then conducted a self-funded national survey of medicine clerkship directors and other key internal medicine faculty to vet, validate, and prioritize the competency agenda and the recommended increase in time for outpatient learning. A remarkable degree of consensus emerged from the survey results, enabling the development of a curriculum reform guide with enhanced emphasis both on outpatient learning and mastery of generalist competencies.
The curriculum guide that emerged from this process comprised five areas: (1) a basic generalist competency agenda, (2) the set of learning objectives pertinent to the competencies, (3) a recommended set of training problems and their associated learning objectives, (4) recommended learning experiences, and (5) a recommended range of time appropriate for outpatient work.28 The group identified, validated, and prioritized 17 basic generalist competencies pertinent to the medicine clerkship. Some of the proposed competencies that scored among the highest include diagnostic decision making, case presentation skills, history taking and physical examination, communication and relationship with patients and colleagues, test interpretation, therapeutic decision making, bioethics of care, self-directed learning, and prevention. The consensus group considered these areas to be mandatory in all medicine clerkships along with increased training in ambulatory settings of up to 30% to 50% of the clerkship experience.
Demand for the curriculum guide exceeded expectations, and a follow-up survey29 indicated that the materials achieved significant dissemination and use among internal medicine educators. Letters of formal endorsement came from all major internal medicine organizations interested in the clerkship, leading to most U.S. medical schools adopting the guide and many, if not most, of the guide's recommendations. Uses of the guide include student orientation, self-directed study, design of lectures and lecture series, faculty orientation and development, structuring the clerkship schedule and content, and, finally, faculty strategies for monitoring preceptorships.28,29
General Internal Medicine Faculty Development Project.
Building on HRSA's emphasis on collaboration and faculty development to enhance the quality of primary care training, the Association of Professors of Medicine in 1997 won a five-year contract after an explicit commitment by the organization to create a leadership team with representatives from six major organizations in internal medicine whose members were involved significantly in medical student and resident education. These organizations included the American College of Physicians, SGIM, Association of Program Directors in Internal Medicine, CDIM, Association of Subspecialty Professors, and Association of Professors of Medicine; their representatives and several other people came together to form the General Internal Medicine Generalist Education Leadership Group (GIMGEL). HRSA asked the group to use the Core Curriculum Guide for the Internal Medicine Clerkship developed under the SGIM contract as a key resource for faculty development workshops.30,31
Recommendations for the core internal medicine clerkship curriculum called for shifting one third of the clerkship experience from an inpatient focus to an ambulatory generalist one to correspond to the reality of changing practice.28 Consequently, the goal of this contract, “Faculty Development for Generalist Faculty Teaching in Community-Based Ambulatory Settings,” was to create national, regional, and local faculty development programs designed to give community-based faculty skills in precepting students and residents in the ambulatory setting. More than 110 teams of generalist and specialist faculty—representing 53 community hospitals and 57 university hospitals—participated in the program, which included four national meetings designed to increase participants' skills in teaching, precepting, and leading faculty development programs.
Each team had to conduct a needs assessment for faculty development programming at its home institution, design a program for implementation, and participate in the national meetings where they engaged in team building and academic skills, such as abstract writing and poster and lecture presentations. Communication between the GIMGEL advisory committee and the teams occurred regularly, and, through consultation and the development of new materials, GIMGEL and program participants learned from each other. An open-access Web site made new resources, including workshop presentations, resource articles, and teaching tips, available. By the conclusion of the contract, 59 of the faculty teams (54%) had implemented at least one faculty development program at their home institution or in their local community. On average, each team educated 22 additional faculty, for an aggregate total of at least 1,760 internal medicine educators nationwide, with the majority being general internists.30,31
General Pediatrics Faculty Development Scholars Program.
Also in 1997, HRSA awarded the Ambulatory Pediatric Association (APA) a five-year contract to provide faculty development for general pediatrics physician faculty who teach general pediatrics to medical students and/or residents in ambulatory community-based settings. The leadership group of this contract, consisting of representatives from the APA, American Academy of Pediatrics, American Board of Pediatrics, Association of Medical School Pediatric Department Chairs, Association of Pediatrics Program Directors, and Council on Medical Student Education in Pediatrics, created a Faculty Development Scholars Program. The program helped create a critical mass of faculty who could enhance pediatric faculty and community-based pediatricians' teaching skills, develop and evaluate programs, and provide leadership to sustain these efforts.
Recognizing the broad backgrounds and needs of potential participants, the national program enrolled participants into one of three tracks: Community-Based Clinical Teaching, Educational Scholarship, and Executive Leadership. Participants were selected on the basis of interest, teaching experience, and regional distribution. There were two cohorts of participants, with each cohort participating in three, two-day workshop sessions during a three-year period (1999–2001). Core content areas for all participants included ambulatory and preventive care, continuity of care, evidence- and systems-based medicine, psychosocial aspects of health, population-based medicine, cost of care, and use of interdisciplinary teams and innovative technology.
One hundred twelve scholars matriculated into the program: 42 in the community-based education track, 38 in the educational scholarship track, and 32 in the executive leadership track. They represented all APA regions, and 18% of the participants were community preceptors, whereas 7% were underrepresented minorities. By October 2001, scholars from the program had presented 438 local workshops and 161 regional/national workshops to a total of almost 8,000 participants. Ninety-nine of the scholars reported organizational and/or infrastructure changes associated with their participation in the program including increased numbers of community teaching sites and preceptors, increased focus on reward systems for community preceptors, commitment of institutional resources for faculty development for community preceptors, and changes in requirements in the medical school curriculum to include community-based educational experiences.32
Enhancing the Quality of Primary Care Through National Curricula in Specific Disease Areas
Project SAEFP (Substance Abuse Education for Family Physicians) was one of the earliest efforts funded by HRSA (1989–1990) to train primary care physicians to recognize and manage substance abuse. Project SAEFP sought to increase the amount of teaching in the area of substance abuse conducted by faculty in the then existing 178 family medicine residency programs. SAEFP workshops were conducted in 10 sites in 1990; 165 family medicine residency faculty learned how to use teaching modules at their own sites.33 A one-year follow-up evaluation documented that those faculty who had received the training did increase their teaching, clinical practice, and consultations in substance abuse.33 Other researchers conducted a more expansive study examining the changes in medical education regarding substance abuse. The authors noted the qualified success of SAEFP, but they commented that the amount of time devoted to this topic by faculty does not equal that devoted to other problems of similar prevalence such as cancer.34
HRSA funded a similar contract to develop a manual on substance abuse for general internal medicine and then awarded another contract to create a manual to help develop both general internal medicine and general pediatrics faculty. Codirected by leaders in general internal medicine and general pediatrics, faculty from both specialties taught sessions on learner-centered learning, alcohol and other drugs, and the management of acute problems. They also conducted skill development group sessions focused on areas such as screening and assessment, primary prevention and anticipatory guidance, making an effective referral, teaching patients about substance abuse, and what faculty learners should do when returning to their home institutions. Instructional sessions also provided faculty tips on educational strategies, information on curriculum development and planning, and advice on use of the 12-step meeting as a learning tool.
Building on these primary care initiatives in substance abuse, leaders of these efforts expanded this training to other health professionals using an interdisciplinary model with close mentorship by senior clinicians through the HRSA/AMERSA (Association for Medical Education and Research in Substance Abuse) fellowship program.35 Project Mainstream, as this project came to be known, currently has a Web site (http://www.jointogether.org/resources/project-mainstream.html),36 which contains modules addressing skills that generalist care professionals can perform in their settings: screening, brief intervention, and referral to treatment; identifying and assisting children of parents with substance use disorders; and helping communities implement effective prevention programs.
As described above, HRSA designed the GPC Project to enhance the ability of generalist faculty to incorporate the clinical application of genetic information into undergraduate and graduate primary care medical education. The specific diseases chosen for focus in the GPC training modules are thought to be prevalent enough in generalist practice to appeal to family physicians, pediatricians, and general internists.10 They include cardiovascular disease, colorectal cancer, breast cancer, developmental delay (fragile X), deafness, and hemochromatosis. Each module comprises learning objectives, two or three cases with a discussion section for the preceptor that focuses on the genetics of the disease, and a set of Web and literature resources for further learning. Drawing on the concept of viewing genetics through a primary care lens, priorities for development of the content centered on evaluating genetic information in terms of patient outcomes, respect for patient preferences, longitudinal care, and protecting patients from overestimation of the benefits and risks of genetic information.10
HRSA extended the GPC contract to enable development of additional resource materials in the areas of (1) cultural competency, (2) red flags indicating the need for genetic consideration, (3) family history, and (4) evidence-based medicine. Through this extension, collaborative interdisciplinary working groups produced new cases, clinical teaching tools such as mnemonics, and Web-based resources.37–39 Four-year follow-up data from faculty participating in the GPC project indicate that it had lasting effects on their teaching and clinical practices in ambulatory settings.40 A Web site (www.genetictools.org) provides a cache of genetics tools, including mnemonics to help primary care clinicians “think genetically,” all of which were initiated through the GPC contract and have since evolved.41
The most significant outcomes of the Title VII contracts awarded to national primary care organizations are increased collaboration and enhanced innovation in ambulatory training for students, residents, and faculty.
Ambulatory education has experienced significant refinement during the past two decades with identification of core generalist competencies—with a targeted focus on specific diseases—that track along the continuum of training from the preclinical and clinical education of medical students, through residency training, to faculty development. Overall, generalist competencies and education in new content areas have been the distinguishing features of these national initiatives, all funded with federal Title VII dollars. This effort has enhanced not only generalist training but also the general medical education of all students, even those studying specialties, because so much of the generalist competency agenda is germane to the general medical education mission.
Collaboration among the primary care generalist disciplines of family medicine, general internal medicine, and general pediatrics would likely not have expanded to its current level without the contract requirements and support of Title VII. Building on the early success of collaboration within primary care, Title VII contracts encouraged greater levels of collaboration as evidenced by the cooperation between the primary care disciplines and medical genetics and between the primary care disciplines and managed care organizations and integrated health care delivery systems. Concepts developed by interdisciplinary approaches, such as viewing genetics through a primary care lens, could not have been achieved without these collaborative approaches.
The shift of medical education to the ambulatory setting and the new curricular innovations for student and resident training as well as for faculty development could not have occurred as dramatically or as quickly without federal funding provided through Title VII. Beginning with the IGC Project, Title VII promoted a model for introducing early ambulatory experiences to all students. The IGC project logically led to innovations through the UME-21 Project, which focused on appropriate ambulatory experiences for students during the latter portion of their training. Innovations in focused topics such as genetics and substance abuse would probably not have been adopted so widely had it not been for the national focus of these curricular elements through Title VII funding.
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