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Medical Training in School-Based Health Centers: A Collaboration Among Five Medical Schools

Kalet, Adina L. MD, MPH; Juszczak, Linda DNSc, MPH, CPNP; Pastore, Doris MD; Fierman, Arthur H. MD; Soren, Karen MD; Cohall, Alwyn MD; Fisher, Martin MD; Hopkins, Catherine RN, MS, PNP; Hsieh, Amy; Kachur, Elizabeth PhD; Sullivan, Laurie CSW; Techow, Beth MEd; Volel, Caroline MD, MPH

doi: 10.1097/ACM.0b013e31803ea911
Educational Strategies
Free
SDC

School-based health centers (SBHCs) have tremendous untapped potential as models for learning about systems-based care of vulnerable children. SBHCs aim to provide comprehensive, community-based primary health care to primary and secondary schoolchildren who might not otherwise have ready access to that care. The staffing at SBHCs is multidisciplinary, including various combinations of nurse practitioners, physicians, dentists, nutritionists, and mental health providers. Although this unique environment provides obvious advantages to children and their families, medical students and residents receive little or no preparation for this type of practice.

To address these deficiencies in medical education, five downstate New York state medical schools, funded by the New York State Department of Health, collaborated to define, develop, implement, and evaluate curricula that expose health professions students and residents to SBHCs. The schools identified core competencies and developed a comprehensive training model for the project, including clinical experiences, didactic sessions, and community service opportunities, and they developed goals, objectives, and learning materials for each competency for all types and levels of learners. Each school has implemented a wide range of learning activities based on the competencies.

In this paper, the authors describe the development of the collaboration and illustrate the process undertaken to implement new curricula, including considerations made to address institutional needs, curricula development, and incorporation into existing curricula. In addition, they discuss the lessons learned from conducting this collaborative effort among medical schools, with the goal of providing guidance to establish effective cross-disciplinary curricula that address newly defined competencies.

Dr. Kalet is associate professor, Section of Primary Care, Department of Medicine, New York University School of Medicine, New York, New York.

Dr. Juszczak was assistant clinical professor, Albert Einstein College of Medicine, New York, New York, at the time of this work. Currently, she is deputy director, National Assembly on School-Based Health Care, Washington, DC.

Dr. Pastore is associate professor of pediatrics, Division of Adolescent Medicine, Mount Sinai School of Medicine of New York University, New York, New York.

Dr. Fierman is associate professor, Department of Pediatrics, New York University School of Medicine, New York, New York.

Dr. Soren is associate clinical professor, Columbia University College of Physicians and Surgeons, New York, New York.

Dr. Cohall is associate professor, Columbia University College of Physicians and Surgeons, New York, New York.

Dr. Fisher is professor, Department of Pediatrics, New York University School of Medicine, New York, New York.

Ms. Hopkins is nurse practitioner coordinator, Department of Family Medicine, New York Medical College, Valhalla, New York.

Ms. Hsieh is project associate, Section of Primary Care, Department of Medicine, New York University School of Medicine, New York, New York.

Dr. Kachur is education consultant, Section of Primary Care, Department of Medicine, New York University School of Medicine, New York, New York.

Ms. Sullivan is medical educator, Department of Family Medicine, New York Medical College, Valhalla, New York.

Ms. Techow is program coordinator, Mount Sinai Adolescent Health Center, Mount Sinai School of Medicine of New York University, New York, New York.

Dr. Volel is assistant clinical professor of pediatrics and population and family health, Columbia University College of Physicians and Surgeons, New York, New York.

Correspondence should be addressed to Dr. Kalet, 550 First Avenue, Old Bellevue, D401B, New York, NY 10016; telephone: (212) 263-1137; fax: (212) 263-8234; e-mail: (ak41@nyu.edu).

Medical educators are being challenged to ensure that students and residents demonstrate competence in a variety of areas, including understanding the system in which they practice.1 Ideally, the more than 1,400 school-based health centers (SBHCs) in the United States are models of cost-effective, community-responsive primary care practice for underserved children and adolescents in primary and secondary schools.2 SBHCs are a model setting for teaching health care trainees to be aware of and responsive to the larger context of health care and to tap into multiple system resources to deliver the highest quality of care. The complex public/ private funding and management structure of the SBHCs reflects the economic and policy issues facing our nation’s health care system.3 The SBHC teams include combinations of physicians, nurse practitioners, physician assistants, nutritionists, health educators, and oral health and mental health providers, making them ideal environments to learn about interdisciplinary work. They serve a defined, vulnerable population, providing continuous and episodic personal biopsychosocial health care, health education, prevention programs, and chronic disease–management activities.2 Practitioners in this setting are expected to participate in quality-improvement activities and to effectively advocate for the SBHCs at all levels of government, through the health care and education systems. The highly interdisciplinary, team-oriented care located within public schools and affiliated with academic medical centers and medical schools represent an underutilized training resource for future physicians and an opportunity to address the issues of systems-based practice and other core competencies identified by relevant accreditation bodies such as the Accreditation Council for Graduate Medical Education (ACGME).4

School health programs, which include SBHCs, have infrequently been used as sites for physician training. Even though recommendations for residency training and continuing medical education in school health have existed for some time, only a minority of pediatricians have received any training in school health.5 Despite the advantages of the SBHCs’ unique environment for children and their families, medical students and residents are not introduced to SBHCs’ practice beyond the core biomedical content of ambulatory pediatric and family practice.

Recognizing this as a barrier to the future growth of SBHCs and the essential training needs of physicians, the New York State Department of Health (NYSDOH) division of graduate medical education provided grant funding for four years to support Medical School Participation in School-Based Health Centers in July of 2002. The downstate grantees, Albert Einstein College of Medicine of Yeshiva University, Columbia University College of Physicians and Surgeons, Mount Sinai School of Medicine of New York University, New York Medical College, and New York University School of Medicine, recognizing the potential afforded by combining efforts, formed the Downstate New York SBHCs Collaborative (DNYSC) to create, in partnership, materials to support new curricular activities for medical, nursing, dental, psychology, and nutrition students in SBHCs and to disseminate the collective experience.

The collaboration helped to amplify efforts to expose health care providers, especially physicians, to practice in SBHCs and other similar community-based ambulatory health care settings through a competency-based curriculum. In this paper, we will describe the process of the collaboration that led to the development of core competencies for trainees at SBHCs, provide illustrative examples of the complex curricula implemented by each school, and discuss lessons learned.

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The Process of Cross-Institutional Collaboration

Defining a comprehensive set of competencies for multidisciplinary trainees

On notification of the grant award, each medical school independently formed a multidisciplinary steering committee, consisting of physicians, nurse practitioners, dentists, social workers, and educators, to identify core competency areas central to SBHC practice and instructional methods to deliver the curriculum to a broad range of health care students. Using a combination of surveys and focus groups with faculty and SBHC practitioners, as well as review of the relevant literature and the requirements of relevant accreditation agencies (e.g., ACGME) and professional organizations (e.g., American Academy of Pediatrics, American Psychiatric Association, National Organization of Nurse Practitioner Faculties, National Assembly on School-Based Health Care), each DNYSC member school independently developed a set of competencies to drive curriculum development. After an NYSDOH grantee meeting that was held six months into the grant period, it became clear that the core competencies developed at each medical school were almost identical and that there would be great value and efficiency in collaborating.

In a series of face-to-face meetings held at six-week intervals throughout the funding period and six months beyond, representatives of each of the five medical schools collaboratively identified eight core competencies for the project: (1) health assessment, risk reduction, and health promotion, (2) the health care delivery system, (3) advocacy, (4) legal and ethical issues, (5) cross-cultural competence, (6) interdisciplinary collaboration, (7) school health practice and education, and (8) oral health (Figure 1 expands on topics covered in each competency). Rather than mandating that all trainees must master all competencies, the intention of this set of competencies was to allow educators from different disciplines to understand how to best take advantage of the scope of training opportunities in SBHCs. For each competency, we created a description and provided goals and measurable, behaviorally specific objectives, interactive instructional methods, clinical case material, discussion questions, and targeted references and resources. Table 1 shows how these competencies overlap with the six competencies proposed by the ACGME for all graduate medical education programs.

Figure 1

Figure 1

Table 1

Table 1

Each DNYSC member school established its own curriculum, reflecting its expertise, preexisting programs, and resources. The group worked collaboratively on refining the competencies, developing teaching materials, planning a shared evaluation strategy, disseminating our experiences through presentations at professional meetings, and on SBHC advocacy projects with local and state government. The collaboration resulted in a high level of accountability for and integration of teaching resources, evaluation tool development, venues for curriculum implementation, and faculty development.

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Moving from baseline to curriculum implementation

Collectively, the five medical schools participating in DNYSC are affiliated with 35 SBHCs (located in 16 elementary schools, 8 middle schools, and 11 high schools) throughout New York City and lower Westchester County. Of these 35 SBHCs, 29 (83%) are located in medically underserved areas and/or health professional–shortage areas.6 Before this project, some of the participating medical schools had a long history of placing health care professional trainees in SBHC settings for preceptorship experiences, whereas others were just beginning to develop training activities in this area. After two years of implementing this project, the collaborative has placed 1,041 physician trainees from the five institutions, ranging from first-year medical students to fellows in adolescent medicine. Strategies used by members of DNYSC to teach the core competencies include enabling clinical experiences in schools, developing and implementing didactic sessions, expanding community service opportunities for trainees, and developing experiences specifically to address institutional needs.

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Clinical experiences.

The DNYSC training programs that had experience placing students in SBHCs for supervised clinical experience began the project with inconsistent participation by trainees. In addition, because of limited physical space and concerns about the possible negative effects trainees have on productivity, SBHC health care providers were cautious about expanding their teaching responsibilities. As a part of this initiative, these concerns were addressed in several programs by providing administrative support, by offering faculty development sessions to improve teaching skills, knowledge, and experience relative to school health, and by developing and distributing teaching tools.

Clinical training experiences offered in the program focused on the needs and level of trainees. For clinically inexperienced trainees (e.g., first- and second-year medical students), training included opportunities to practice communication skills and interview techniques. Clerkship-level students, nursing students, and pediatric residents were assigned to an SBHC to study adolescent care and community pediatrics. SBHCS were also used for continuity core training for residents and advanced practice nursing students. Dental students and dental residents implemented schoolwide screening and sealant programs and practiced principles of dental public health. Examples of some of the clinical issues that were highlighted include adolescent health, sports medicine, approaches to educational problems, and care of children and adolescents with chronic illnesses.

For the most part, medical students and residents worked closely with and were taught by nurse practitioners practicing in the SBHCs. They also worked beside other members of the team (e.g., social workers, oral health technicians). From debriefings, we know that they left with a better understanding of the roles, responsibilities, and capabilities of these professionals. This type of experience is rare in a hospital setting.7

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Didactic sessions.

Although there was some relevant formal curriculum in the medical schools and residency training programs before the implementation of this project, it often occurred in isolation from an actual clinical experience and was not integrated in a systematic way. Accordingly, each participating medical school developed didactic sessions for trainees in the training programs. These didactic sessions addressed specific issues relating to school health practices and SBHC programs (i.e., screening in schools, consultation and collaboration with schools, sexuality education, and managing crises). The content of these sessions was shared across the members of the collaborative by creating an electronic compilation of the materials from these sessions. The electronic file has been updated and distributed periodically as new learning modules become available. For DNYSC schools with Web sites dedicated to SBHC training, sessions were made available to students through the schools’ intranet.

The goal of DNYSC was to provide a learning environment that was multidisciplinary and that focused on evidence-based practice. In some instances, a more intensive seminar series was developed addressing the eight previously described core competencies (see Figure 1 for possible topics) and was offered through a previously existing elective seminar program. Another program identified opportunities to integrate didactic sessions into the overall medical school preventive health curriculum. At one member school, all first-year medical students participated in a walking tour designed to highlight the unique cultural aspects of the SBHC community to teach about the history of social issues and activism that characterized that neighborhood.

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Community service opportunities.

All DNYSC schools availed themselves of the opportunity provided by these projects to expand and improve community service experiences for health care students and residents. Most of the programs included trainees in advocacy activities in the state capitol, in the implementation of health education curricula in the classroom, and in the development of projects to address specific health issues such as obesity and healthy eating.

One program developed a series of special projects in which residents and medical students serve as mentors and health educators for middle and high school students. At another training project, third-year medical students join the children during school lunch for an informal exchange. Through this session, the children are encouraged to recognize their contribution to the education of “my doctor.” The medical students also participate in a case-based module and interactive discussion of childhood attention-deficit/hyperactivity disorder.

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Addressing institutional needs.

For these programs to demonstrate their value, members of the collaborative needed to be certain that the formal teaching efforts, clinical experiences, and community service opportunities were complementary but not redundant with existing curricula. In addition, projects became an opportunity to address institutional accreditation needs (i.e., the enhancement of public health, systems-based practice, and communication skills curricula) without creating an excessive number of new required curricular hours. Those trainees particularly interested in enhanced education in this area have access to a combination of didactic, community, and clinical experiences. Less intensive learning experiences related to SBHCs were added to an adolescent health rotation and to required medical school courses on health systems and economic models.

As a result of the array of new curricula introduced at each school, a substantial number of trainees, the majority of whom are medical students and residents, and a significant number and variety of patient populations, have been affected by the curricular programs at the SBHCs. All training programs reported stronger efforts at internal collaboration with residency training directors, clinical course coordinators, and departmental education directors to fit school health experiences into various course curricula. Table 2 details some of the potential interests and gains the many stakeholders in SBHC training sites can derive from such educational programs.

Table 2

Table 2

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Development of common evaluation instruments

Since the initiation of the collaborative, there has been a commitment to develop a shared set of evaluation tools. We generated and pilot tested instruments to measure the immediate educational impact (pre–post) of curricula on the following outcomes: trainees’ knowledge (65 multiple-choice questions), attitudes (15 strength-of-agreement items), and level of comfort (16 strength-of-agreement items), as well as post-only satisfaction (8 items) and activity log. A pre–post design study of the collaborative is currently underway. Preliminary data from the first 206 trainees representing a range of trainee levels at three schools have allowed us to refine the knowledge test to 15 items with appropriately challenging distracters, moderate difficulty, and maximum discrimination. Attitude-scale development is in progress. Preliminary item analyses suggest the strongest impact of the curricula is on trainees’ attitudes toward the relevance and importance of interdisciplinary team work. (Outcome instruments are available from the first author on request.)

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Discussion

Educators all over the country are confronted with how to prepare medical, nursing, and dental students for practice in the rapidly changing health care environment. While continuing to ensure rigorous clinical training, educators struggle to provide trainees with adequate ambulatory and community- based experiences, a sophisticated understanding of how the systems in which they will work function or are financed, and exposure to public health, patient, and health care advocacy. Our endeavor to implement curricula in SBHCs collaboratively is relevant to the many audiences struggling with these issues.

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Ingredients of effective collaboration

The literature supports the experience described here, demonstrating that successful collaborations benefit from having (1) excellent partnering relationships among people who have a history of collaborating, (2) a focused planning and implementation phase that has a clearly articulated vision and purpose, (3) members viewing the collaboration as mutually beneficial, (4) a shared stake in both the process and the outcome, (5) regular and open communication using a common language, but (6) flexibility for individual expression, and (7) sufficient funds and time to enable the work.8 Already invested in SBHCs as clinicians, the participants of the DNYSC have worked collaboratively across disciplines in the past, which promoted healthy partnering relationships that enabled this training initiative. The Institute of Medicine recently has recommended that “all health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team” as a core ideal for our national health policy.9 Consequently, the SBHC curriculum collaboration reflects the interdisciplinary process of the DNYSC leadership team and ensures a diversity of perspectives in the planning, implementation, and “tearing down of walls” among the traditional education silos. This rapport, interdisciplinary respect, and the visibility of the work made it possible to successfully confront the challenges to the collaboration that were posed by interinstitutional and interdisciplinary politics. On the basis of the experiences of this collaborative, potential stakeholder interests and opportunities in SBHC training programs can be defined and summarized (see Table 2).

At the initial gathering of DNYSC members in 2002, participants delineated the goals of the collaboration and the steps necessary to achieve them. One of the key components to the planning portion was an agreement to share what each group developed individually, including core competencies, didactic learning modules, and evaluation tools, and to maintain open communication on future curricular developments. Collaborative members occasionally participated directly as teachers at each others’ training efforts and shared the advice of consultants. Lastly, the group planned to collaborate on evaluation efforts, though not before fully developing appropriate evaluation tools together. These initial resolutions continue to guide the initiative today. Once the vision and purpose of the initiative were determined, it became clear to the participants that collaborating brought enormous benefits to the quality of the materials generated and saved time for the participants. Having a shared stake in both the process and the outcome created ownership and generated and perpetuated enthusiasm for the work. Many say that a common language greatly facilitates the incorporation of competency-based training and evaluation across health professions education.10 Through a common vocabulary and set of objectives, each member school was able to reach agreement on the meaning and scope of our curricular innovations, to provide the needed materials (e.g., a CD-ROM of core lectures related to school health and clinical issues in SBHCs), and to create faculty development curricula. As a collaborative, this project allowed each partner school to contribute its unique strengths to a common resource pool shared among the partner institutions and their respective schools of health education.

Although all of the DNYSC member schools worked from a unified conceptual model of eight core competencies, given the great diversity in clinical sites and faculty resources, each school found it essential to have the autonomy to develop and establish its own curriculum and to define its scope. This not only ensured appropriate models for each site; it also unleashed the creativity and enthusiasm needed for effective implementation and dissemination of this complex project.

There is no doubt that a common funding source was essential to create this collaborative, because it was what brought us together and allowed face- to-face meetings among the school representatives every six weeks through the funded period. However, there are many nonmonetary incentives to our continued collaboration after the funding stopped. These incentives include the momentum gained from having established productive working relationships and breaking down barriers to inter- and cross-disciplinary training, the reputation for educationally valuable experience that the SBHCs have developed with trainees, and the expanded capacity of the SBHCs to provide nonclinical programming for schoolchildren provided by supervised trainees. It is our hope that sharing this experience will enable others to become aware of the no-cost or low-cost benefits of collaborating identified in this paper.

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Benefits of collaboration

As a result of these successful collaborative efforts, DNYSC was able to enjoy many benefits that they otherwise may have forgone had they worked individually. These include accountability, a stronger voice in advocacy, and national visibility.

A high degree of accountability resulted from the commitment of the DNYSC members to open communication on our curricular developments. Seeing each others’ effort in developing curricula promoted creativity and provided motivation to move forward at our own schools. Member characteristics as well as the process and structure of the group supported the degree of accountability in this initiative. The initiative was jointly owned, and members shared a stake in the outcomes. Because the DNYSC comprised five medical schools in New York state, each member was able to represent a large constituency when it was time to defend this training initiative to the NYSDOH. Consequently, the group was able to conglomerate advocacy efforts into a more audible voice. Working as a collaborative also has been useful in advocating for future funding for the educational project, in advocating for clinical services, and in stimulating support from key constituencies, including school principals, parent association leadership, medical school deans, and curriculum committees.

Lastly, the engagement of five schools allowed this work to affect a large group of learners and, therefore, gave the project broader scope, application, and potential impact. The five schools have different emphases on the level of learner and the types of activities they were implementing. Faculty and staff in the program came from various disciplines and medical specialties; thus, dissemination of the DNYSC’s efforts was broader.

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Conclusion

Despite the acknowledged difficulty of introducing new interdisciplinary, community-oriented, competency-based curricula into clinical training,11 this five-school collaborative successfully developed and established curricula that prepare practitioners from multiple health professions disciplines to practice in SBHCs serving underserved children. The group was able to accomplish this in the face of significant obstacles, including the ubiquitous competing priorities for busy clinical sites, decreased faculty time available for teaching, regular threats to funding, and faculty and student resistance to change in an already tightly scheduled curriculum.

Through a collaborative consisting of five medical schools and including a broad array of health professionals, we have defined and established core educational competencies for SBHCs that align with the needs of accreditation using a common language, and we have implemented an innovative curriculum in a setting that provides service to vulnerable communities. The lessons learned from this collaborative may guide future interinstitutional and interdisciplinary partnerships that address emerging medical education competencies while also seeking to prepare a workforce to address disparities in health care.

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Acknowledgments

This project was funded by a grant from the New York State Department of Health, Medical Schools Participation in School-Based Health Clinics and Ambulatory Sites (Contract Number C-018200).

Previous versions of this material have been presented at the New York State Department of Health: 6-Month Progress Report (March 4, 2003; Albany, NY); New York University School of Medicine, Grand Rounds: School-Based Health Care for Children and Youth (July 8, 2003; New York, NY); School Based Health Center Training Collaborative meeting (April 26, 2004; Albany, NY); National Assembly on School Based Health Care Conference (June 21, 2004; New Orleans, La); Association of Medical Schools: Medical School Participation in Ambulatory Care and School-Based Health Centers Grant Programs (September 21, 2004; New York, NY); The Generalists in Medical Education Conference 2004: Medical School Participation in School-Based Health Clinic—A Model for System-Based Practice Learning (November 7, 2004; Boston, Mass); and the Society of Adolescent Medicine Annual Meeting 2006: What Has School Got to Do With It?!! (March 24, 2006; Boston, Mass).

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