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Training U.S. Medical Students to Care for the Chronically Ill

Pham, Hoangmai H. MD, MPH; Simonson, Lisa MD; Michael Elnicki, D MD; Fried, Linda P. MD, MPH; Goroll, Allan H. MD; Bass, Eric B. MD, MPH

Special Theme Research Report

Purpose The growing prevalence of chronic illness has important implications for the training of all physicians. The authors assessed the degree to which undergraduate medical curricula explicitly address chronic care competencies selected through literature and expert review.

Method In 2001, trained student assistants interviewed directors of required medical school courses (internal medicine, pediatrics, family practice, and ambulatory care clerkships; longitudinal care; and other relevant courses) at 16 representative U.S. medical schools sampled by geography, curriculum reform activity, and primary care orientation of graduates. Course directors were asked whether chronic care competencies were addressed using specific curricular methods (written objectives, course materials, observational evaluations, written/oral examinations, other required course activities), and to rate the importance (1 = not important; 5 = essential) of each competency for their course and for the overall undergraduate curriculum.

Results All 70 eligible course directors responded. Of 49 chronic care competencies, 29 (59%) received mean importance ratings for a course of ≥ 3, but only 14 (29%) were addressed using two or more specific curricular methods. Course directors gave highest importance ratings (mean > 3.9) to screening for abuse, awareness of patients’ sociocultural perspectives, and protecting patients’ confidentiality. They gave lowest importance ratings (mean ≤ 2.6) to knowing strategies to maximize patients’ potential, ability to discuss alternative information sources, and ability to assess equipment needs. Their importance ratings correlated only moderately with the number of curricular methods used to address each competency (r 2 = 0.27–0.80, p < .05).

Conclusion Course directors agreed about the importance of many competencies in chronic care but reported considerable variation in how they addressed competencies in their courses. Medical schools can improve training in chronic care by paying greater attention to specific methods for addressing important chronic care competencies.

Dr. Pham is senior health researcher, Center for Studying Health System Change, Washington, DC; Dr. Simonson is assistant professor of medicine, Dr. Fried is professor of medicine and epidemiology, and Dr. Bass is associate professor of medicine, Division of General Internal Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland; Dr. Elnicki is section chief, Division of General Internal Medicine, University of Pittsburgh School of Medicine, Pennsylvania; Dr. Goroll is associate professor of medicine, Massachusetts General Hospital, Boston.

Correspondence and requests for reprints should be addressed to Hoangmai H. Pham, MD, MPH, Senior Health Researcher, Center for Studying Health System Change, 600 Maryland Avenue, SW, Suite 550, Washington, DC 20024; telephone: (202) 554-7571; fax: (202) 484-9258; e-mail: 〈〉.

Chronic illnesses are the major cause of medical care utilization, disability, and death in the United States today,1 and they will only become more burdensome as the population ages and better treatments become available for acute illnesses. Projections indicate that by the year 2050, 167 million Americans will have a chronic condition.2

Despite the growing burden of chronic illness, today’s physicians may be poorly prepared to address the complex medical and psychosocial needs of chronically ill patients.3–7 Current medical training may not adequately emphasize health promotion and disease prevention, supportive care, patients’ self-management, and the integration of care from multiple physician and nonphysician providers in nontraditional settings and partnerships.8–10 Deficits in training may be compounded by a medical culture that emphasizes the rewards of acute disease management while de-emphasizing or casting chronic care in a negative light.11–14

Although commentators have generated a growing list of competencies that are potentially important to the care of the chronically ill,8,15 medical schools’ attempts to address these competencies have been sporadic and rarely comprehensive. Schools report little experience with appropriate methods for teaching chronic care such as team-oriented exercises or using alternative training sites (e.g., patients’ homes and rehabilitation centers).16–18

Physicians need to be trained to engage chronically ill patients and their families in their own care and to coordinate the entire continuum of care. To assess whether competencies relevant to care for the chronically ill are being explicitly addressed in required courses in U.S. medical schools, we performed in-depth interviews with directors of required courses at a representative sample of U. S. medical schools.

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To obtain more detailed information than is reasonably available from a telephone or mail-in survey of a large number of schools, we conducted structured in-person interviews of course directors at 16 representative U.S. medical schools in 2001.

To identify a representative sample of schools, we first stratified all medical schools by geographic region (east versus west of the Mississippi). Within regions, we further stratified schools by amount of curricular reform activity based on our consultation with the Division of Medical Education at the Association of American Medical Colleges. We selected four schools within each of the resulting four categories (east/active reform, west/active reform, east/traditional, west/traditional): at least one public and one private school, one above the 50th percentile for the percentage of graduates intending to enter a primary care residency and one at or below the 50th percentile. We obtained data on the graduates’ residency intentions from the American Medical Association’s 1999–2000 Liaison Committee on Medical Education Annual Medical School Questionnaire Part II. (Primary care was defined as including residencies in internal medicine (IM), family practice (FP), pediatrics, combined IM/pediatrics, and combined IM/FP.)

Fourteen schools were recruited to participate via telephone calls to the education/curriculum dean’s office; two schools were recruited by advertising among members of the Clerkship Directors in Internal Medicine. A faculty member at each school agreed to serve as a liaison to the research team. The selected schools are listed in the Appendix.

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Selection of Course Directors

Because we wanted information on the curriculum content that all students at a school received, we targeted directors of required courses in six categories: (1) IM clerkships, (2) pediatrics clerkships, (3) FP clerkships/rotations, (4) ambulatory care clerkships/rotations, (5) longitudinal care courses/rotations (defined as a curriculum experience lasting at least six months during which students are expected to observe or provide continuity of care over time), and (6) one “other” course, exclusive of those above, that in the judgment of the faculty liaison contained the most curriculum material relevant to care of the chronically ill (e.g., courses on physicians and society, ethics, geriatrics, or home visitation programs). Each school had a minimum of two and maximum of six eligible course directors. We chose the six course categories because we felt their curricular contents were likely to be relevant to chronic care. We included longitudinal and “other” courses because schools might have addressed chronic care competencies in diverse settings other than traditional clinical rotations.

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Competencies in Chronic Care

The interview instrument contained questions about 49 competencies relevant to care of patients with chronic illness, grouped within 18 general domains (see Table 1). We identified the competencies by reviewing literature on curricula that address chronic illness, palliative care, and end-of-life care.10,15,19–25 Each set of competencies in a domain was reviewed by at least two members of our faculty with relevant expertise. The modified list of competencies in each domain was then circulated for review by at least two external reviewers with relevant expertise. External reviewers included clinicians, educators, investigators, representatives of patient advocacy organizations, and health policy makers. We then obtained input from members of an advisory panel consisting of representatives from the Association of American Medical Colleges, the American College of Physicians-American Society for Internal Medicine Foundation, the American Geriatrics Society, the Chronic Care Consortium, Clerkship Directors in Internal Medicine, and Partnerships for Solutions (a program funded by the Robert Wood Johnson Foundation that seeks to develop strategies for improving care for people with chronic conditions). Finally, we piloted the survey instrument among directors of all eligible courses at our institution and made only minor revisions based on their comments. We intended for the multiple levels of review to maximize the face validity of the instrument’s content.

Table 1

Table 1

Table 1

Table 1

Table 1

Table 1

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Interview Instrument

For each competency, we asked course directors five yes/no questions regarding methods they used in their courses to explicitly address the competency. These methods were inclusion of the competency in (1) written course objectives, (2) written handouts or lecture materials, (3) observational evaluations of students, (4) written or oral exams evaluating students, and (5) specific required course/rotation activities (e.g., home visits, team care meetings, family meetings, didactic sessions, or nursing home visitations). We then asked the course directors to rate the importance of each competency for (1) their specific course and (2) the overall undergraduate medical curriculum at their school on a five-point scale (1 = not important, 3 = moderately important, 5 = essential). We asked the course directors about their clinical specialty and training and characteristics of their courses (duration, use of specific training sites, use of formal curriculum guides, and types of required course activities). We asked three open-ended questions at the close of the interview about the course directors’ opinions of the interview’s ability to measure how well their courses addressed chronic illness.

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Data Collection

We consulted a faculty liaison at each school to identify eligible courses. Through the faculty liaison at each school, we recruited a medical student to interview all eligible course directors at that school. Because interviews were highly structured, there was no criterion based on the student interviewers’ year of training or previous exposure to the eligible courses. Each student-interviewer was trained by telephone through mock interviewing in one-on-one sessions with a member of the study team. The interviews were completed over a two-month period in 2001, and interview data were returned to us by mail. Interviewers obtained verbal consent from course directors. The Johns Hopkins University Joint Committee on Clinical Investigation approved the protocol.

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Data Analysis

We calculated mean importance ratings for each competency by course type, school, and the total study population of course directors. We also calculated the percentage of course directors reporting the use of a particular curriculum method in addressing each competency. We created a summary measure of the extent to which each course explicitly addressed each competency by summing the number of “yes” responses to the five questions on use of specific curriculum methods (the summary methods measure).

For each competency, we calculated a coefficient for the correlation between the summary methods measure and course directors’ importance rating for their course, using a Spearman p value of .05 for significance. We further explored this association using bivariate linear regression analyses with the summary methods measure as the independent variable and course directors’ importance rating as the dependent variable. Finally, we tabulated course directors’ narrative responses to questions about how well they believed the interview captured chronic care content in their courses. All analyses were performed using Intercooled Stata, Version 6.0 software (Stata Corporation, College Station, Texas).

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School and Course Characteristics

All 70 eligible course directors at the 16 schools participated (4.4 respondents per school). Ten course directors were professors, 34 were associate professors, and 24 were assistant professors. The most common specialties among course directors were FP (21), general IM (16), cardiology (11), and general pediatrics (11). Eligible courses are described in Table 2.

Table 2

Table 2

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Curricular Methods Applied to Chronic Care Competencies

Table 1 summarizes the number and type of curricular methods used in courses to address each of the 49 chronic care competencies, grouped in 18 domains. A majority of course directors reported using two or more curricular methods for only 14 (29%) of the competencies. Only one competency (ability to screen patients for physical, mental, and emotional abuse) was included in written objectives for a majority of courses, and only one competency (age-specific management of dementia/cognitive impairment) was included in examinations for a majority of courses. Five competencies (screening for abuse; diagnosing drug addiction, dependence, and tolerance; management of dementia/cognitive impairment; recognizing risk factors for nutritional deficiency; and awareness of ethical issues in end-of-life care) were included in written materials for a majority of courses. Only two competencies (screening for abuse and ability to discuss death and dying with patients) were included in required activities in a majority of courses. More competencies (13) were addressed in a majority of courses through observational evaluations of students than through any other curricular method.

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Importance Ratings by Directors for Their Own Courses

The 70 course directors gave the 49 chronic care competencies an overall mean importance rating of 3.2 (standard deviation = 1.4) for their course (see Table 1), with a broad distribution of ratings, including 573 (17%) competency ratings of not important, 518 (15%) ratings of mildly important, 796 (23%) ratings of moderately important, 869 (25%) ratings of very important, and 674 (20%) ratings of essential. The 14 competencies given mean importance ratings greater than or equal to 3.5 included attitudes (e.g., positive attitudes toward the chronically ill), knowledge (e.g., knowledge of ethical and legal end-of-life care issues), and skills (e.g., ability to teach patients self-care and ability to discuss death and dying with patients). The 14 competencies rated most important for a course represented eight of the 18 competency domains: home environment assessment, attitudes and perspectives regarding chronic care, use of medical informatics in chronic care, end-of-life care, management of psychosocial aspects of chronic illness, pharmacology, chronic-pain management, and patient self-management. In contrast, competencies receiving the lowest importance ratings for a particular course were clustered in a limited number of competency domains. Eight of the 14 competencies receiving mean importance ratings less than 2.9 were related to the domains of home environment assessment, coordination of care between generalists and specialists, and long-term management of specific geriatric or pediatric problems such as incontinence or developmental delay.

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Importance Ratings for Overall School Curriculum

Course directors generally gave competencies higher importance ratings within the context of an overall medical school curriculum than within the context of their individual courses. They rated the 49 competencies a median score of 4 (interquartile range = 3 to 5; see Table 1). There were only 61 (2%) ratings of not important and 207 (6%) ratings of mildly important. The remaining ratings were 719 (21%) of moderately important, 1,164 (34%) of very important, and 1,279 (37%) of essential. Of the 14 competencies rated most important within a particular course, nine were also among the 14 rated most important (mean rating ≥ 4.3) for the overall medical school curriculum. The remaining four competencies rated most important for the school curriculum were related to domains of pharmacology, palliative care, long-term management of specific conditions, and management of psychosocial aspects of chronic illness. Course directors gave lowest ratings for importance in a school curriculum to many of the same competencies they gave lowest ratings for importance in their course curriculum. Nine of 14 competencies receiving the lowest mean ratings for a school’s curriculum were also among the 14 receiving lowest mean ratings for a course curriculum. These competencies were related to domains of coordination of care between generalists and specialists, assessment of in-home and community services, use of medical informatics, prevention and health promotion, assessment of home environments, occupational/rehabilitative medicine, and assessment of patients’ functional abilities.

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Importance Ratings and Number of Curricular Approaches Used within Courses

Table 1 displays the coefficients of correlation between the importance ratings that individual course directors gave for each competency and the number of curricular methods course directors reported using to address that competency in their courses, with the r 2 ranging from 0.27 to 0.80 (Spearman p values < .05). For ten of 29 (34%) competencies with mean course importance ratings greater than 3 (moderately important), the majority of course directors reported using only one or no curricular methods to address the competency. These competencies included the ability to perform quantitative pain assessment, awareness of methods to maximize treatment adherence, knowledge of pathophysiologic links between obesity and prevalent chronic diseases, ability to name activities of daily living and instrumental activities of daily living, ability to assess patients’ decision making capacity, ability to discuss with patients their views on autonomy and quality of life issues, ability to assess patients’ self-care skills, ability to assess caregiver and family needs, awareness of community services available for the chronically ill, and having positive attitudes toward the chronically ill.

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Course Directors’ Narrative Comments

In responses to open-ended questions, 34 course directors indicated that the structured interview did not fully reflect chronic care content in their courses: 12 mentioned the inability of the interview to capture implicit inclusion of chronic care competencies and the variability of patient care experiences during clinical rotations, and ten felt the interview’s content was not entirely appropriate for their course (e.g., some IM clerkship directors felt many competencies were better addressed in other, outpatient rotations) or did not sufficiently address evaluation methods. Three respondents thought questions on teaching methods could have been more in-depth to reflect the amount of effort devoted to each competency, and the remaining nine respondents gave no explanation. The most commonly reported implicit teaching methods were observations of student–patient interactions and development of history-taking and communication skills.

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The growing prevalence of chronic illness has important implications for the training of nearly all physicians and, especially, of primary care physicians. In our study of a representative sample of U.S. medical schools, the directors of required undergraduate courses agreed about the importance of many competencies in chronic care but reported considerable variation in their level of commitment to teaching the competencies, ability to fit specific content into their courses, and whether they explicitly addressed the competencies in their courses.

Course directors generally agreed that competencies related to home environment assessment, coordination of care between generalists and specialists, and long-term management of specific geriatrics or pediatrics problems were least important among those listed. These competencies may be least amenable to inclusion in undergraduate courses and may be more appropriate in residency curricula. They gave the highest importance ratings to a diversity of competencies, which suggests either that they consider many competencies deserving of attention or that there is less consensus regarding which competencies should receive the highest priority in course curricula. However, most competencies (92%) received ratings for inclusion in the overall medical school curriculum of moderate or higher. In part, this may reflect the limitations of current course structures in addressing certain competencies. For example, any single clinical rotation may not be able to address appropriate use of in-home and community services. It may suggest that educators may already be attuned to the public debate on chronic care priorities, thus providing the necessary foundation for broader curriculum reform efforts.

Similarly, despite a moderate to high correlation between course directors’ ratings of competency importance and the number of curricular methods they reported using to address these competencies, many competencies with importance ratings of moderate or higher were addressed with only one or no curricular methods. Again, this may reflect limitations in course structure or resources or may actually signal that competencies were not prioritized in curricula as highly as their perceived importance would suggest they ought to be.

The strengths of this study were the inclusion of a representative sample of schools, the targeting of required courses to reflect what all students at each school were exposed to, detailed assessments of curriculum content and methods, and a 100% participation rate among eligible course directors.

Our study had several limitations. First, we interviewed course directors at only a small number of schools with necessarily limited generalizability. However, we believe that this detailed needs assessment provided more information than would a more superficial survey of a larger population. Moreover, our predetermined selection criteria resulted in a diverse sample of schools. A second limitation is that our use of expert opinion to define chronic care competencies may reflect biases, for example, related to reviewers’ interest in particular topics. Third, many relevant competencies may be implicitly addressed during daily interactions between faculty and students or in direct patient contact, which our interviews would not have captured. Course directors’ comments in open-ended questions about the structured interview confirm this. However, our focus on the explicit inclusion of competencies allows a more objective assessment of the commitment that course directors have toward teaching specific competencies and the degree to which all students are exposed to such material. Furthermore, one would expect courses to include competencies considered important at least in written course objectives, even if those competencies are only taught implicitly in individual interactions. However, only one of 49 competencies (ability to screen for abuse) was included in written objectives by a majority of courses. A fourth limitation is that our interviews focused on current course curricula and may not reflect schools’ ongoing curriculum reform activities. Fifth, social desirability may have biased our results, particularly because course directors were interviewed individually. However, we found significant variations in the mean importance ratings for each competency and the number of curricular methods used to address them. Finally, our results should not be interpreted as a “report card” on the performance of undergraduate medical curricula regarding chronic care. Medical schools are undoubtedly addressing chronic care competencies not included in our interviews and, conversely, cannot be expected to address every competency described. To maximize validity, we based our list of competencies on a thorough literature search and extensive reviews by experts in the field. Then, to capture variation in the number and degree to which courses address competencies, we included a number of competencies (such as the ability to name activities of daily living) that would be considered “cutting edge” for current curricula. Including all or even most competencies in a course may be “overkill” and could diminish the impact of the effort. Addressing some well may be more effective.

In conclusion, we found that directors of undergraduate courses most likely to include chronic care content largely agreed about the relative importance of a range of chronic care competencies, but they have widely varying commitments to including them explicitly in their courses’ curricula. These results can provide a basis on which to assess and build a national consensus among educators on how to prioritize the teaching of chronic care competencies in undergraduate medical curricula.

We thank the student interviewers who assisted with data collection: Aaron Lehman, Vladimir Sinkov, Gary Vaughn, Rhonda Williams (Gentry), Rica Bonomo, Josie Pielop, Catherine Baker, Janet Moore, Rebecca Lam, Jennifer Ash, Charmi Patel, Julia Labarge, Dan Shodell, Sarah Winters. This work was funded by grants from the American College of Physicians-American Society of Internal Medicine Foundation, and the National Heart, Lung, and Blood Institute (grant HL07180). Results were presented at a meeting of the Clerkship Directors of Internal Medicine, Washington, DC, October 2002.

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Representative Sample of 16 U.S. Medical Schools Selected for Structured Interviews on Curricular Content of Care for the Chronically Ill, 2001

Albert Einstein College of Medicine of Yeshiva University

University of Arizona College of Medicine

University of Arkansas College of Medicine

Baylor College of Medicine

Johns Hopkins University School of Medicine

Medical College of Wisconsin

University of Missouri-Columbia School of Medicine

Mount Sinai School of Medicine of New York University

Saint Louis University School of Medicine

Southern Illinois University School of Medicine

University at Buffalo State University of New York School of Medicine and Biomedical Sciences

Temple University School of Medicine

University of California, Irvine, College of Medicine

University of California, Los Angeles, School of Medicine

University of Nebraska College of Medicine

University of Pittsburgh School of Medicine

© 2004 Association of American Medical Colleges