assess the overall relevance of this program for medical ... Community Medicine at Kentucky, was the ... "Public health" is a traditional and meaning¬ .... of the medical centre; now they may see the .... As a measure of future interest, we have.
Medical Education 725
Canad. Med. Ass. J. Sept. 16, 1967, vol. 97
The
Community Medicine Program in Kentucky H. S.
FULMER, M.D.,* Lexington, Ky., U.S.A.
Department of Community Medicine, at THE the University of Kentucky College of Medi¬
cine, is now in its seventh year of operation. Founded as one of the original departments of the new medical school, it has introduced a new teaching program into the undergraduate cur¬ riculum.1' 2 The program, as judged by its very biased founders, has been an overall success. In this paper I shall review the history of this new idea, outline the teaching program and cite some of its attributes, some of its problems and some of the newer developments as the department has matured. I shall leave it up to the reader to assess the overall relevance of this program for medical education in general. History The idea that led to this
teaching program reservation in began on the10Navajo Indian Arizona about years ago. At that time respon¬ sibility for medical care of the Indians had been Affairs
transferred from the Bureau of Indian the United States Public Health Service (U.S.P.H.S.). On contract from the U.S.P.H.S., a field health research project had been set up on the Navajo reservation by the Department of Public Health at Cornell University, under the chairmanship of Dr. Walsh McDermott. Dr. Kurtof Deuschle, now chairman of our Department Community Medicine at Kentucky, was the director of the Navajo project, and I served as field director. We gave direct medical care to the Indians in order to warrant the conduct of our operational and epidemiologictheresearch. Among other activities we developed concept of the visitor.an health all-purpose health Navajo technician serving under the public nurse, whose scope and effectiveness was thereby greatly in¬ creased. We also had assigned to us a series of senior medical students from Cornell University. They had chosen this program ofas an elective, and their assignment consisted carrying out field research as well as engaging in clinical work. The idea that later led to the development of our program at Kentucky was generated by the attitude of these students who said, in effect, that "if this is public health, we like it." When Dr. Deuschle accepted the position as chairman of the new department in a new medi-
to
Presented at the Second Western Conference on Medical Education, Vancouver, B.C, December 5-7, 1966. ?Professor of Community Medicine, University of Ken¬ tucky College of Medicine. Lexington, Kentucky, U.S.A.
cal school in Kentucky, he decided to see if he could create a teaching program which could stimulate and excite all medical students, not just a select few, to view medicine in its larger dimensions as these Cornell students had.
Kentucky Origins Dr. William R. Willard, the dean of the medi¬ cal school at Kentucky, gave ample moral and He wanted logistic support to the new venture. a strong department in the area of public health and preventive medicine, and he underwrote whatever Dr. Deuschle wished to do in order to bring this about. Thus, a liberal budget, ample space, adequate staff, and, crucially, prime cur¬ riculum time were made available for the new
department. What's in a Name? The immediate question that arose was what the new department was to be called. When faced with the task of creating a new depart¬ ment in a new medical school, in an area of study that has traditionally failed to fire the imagination of medical students throughout the country and the world, is choice of name impor¬ tant? We called the department "Community Medicine". Why not "Preventive Medicine" and/ or "Public Health"? We felt that the broad definition of "Preven¬ tive
Medicine", which
is
now
widely used,
is
merely "good medicine". For example, the con¬ cept of the "five levels" of prevention commonly emphasized by the classic departmenttheimplies indi¬ that one is attempting always to keep vidual from getting sick or the patient from getting worse and to restore him to health. Al¬ though all clinical departments are not really teaching the concept wholeheartedly, they should be, and many of them are. Certainly any good clinical teacher in a medical school should be teaching primary prevention of disease as well as diagnosis, prompt treatment and reha¬ bilitation. Nevertheless, in the hospital-bedside setting it is difficult and often contrived to
emphasize preventive principles in the face of the patient for whom diagnosis and treatment are the immediate concern. Thus, even when a clinical teacher wants and tries to teach preven¬ tive principles, he is stymied by the usual set¬ to give ting in the ward or even the clinic. Yet, the department the title "Preventive Medicine" fails to charm the medical student because he
726 Medical Education
tends to see prevention as somewhat separate from the clinical areas. "Public health" is a traditional and meaning¬ ful term, but it also has a negative connotation among medical students. How many of us be¬ came inspired by the field of public health in medical school by virtue of the teaching that was done by a department with that name? In my own class at a school of public health, we surveyed ourselves and found that virtually the entire physician group became interested in medical public health several years after leaving the school. As medical students, we have in past come away from medical school perpetuating the dichotomy between public health and the "mainstream" of medicine. We have thought of public health as a "poor second cousin" populated by those who couldn't make it in the "real" world of medicine. And this thinking has been greatly influenced by poor teaching programs in many medical schools. Most important, how¬ ever, the definition of "public health" includes, traditionally, only organized effort to solve com¬ munity health problems. It does not encompass what the practising physician might do as an individual and, since most medical students do go on to become private practitioners, they tend to look upon public health as separate or peri¬ pheral to their interests. What were we really trying to do by creating this new department? We were attempting to complete the educational evolution of the medi¬ cal student. This was to be dqne by embracing the third major step of medical education which was conceived to consist of laboratory, clinical and community medicine. We felt that the third step was lacking in most teaching programs. If the student learns the application of the basic sciences in the laboratory, and the application of the clinical sciences at the bedside, then the analogy is that he learns the application of the scientific approach to the community in the community. And, in the community, there are not only groups of people, there are individuals. Therefore, in a sense the concept includes public health and preventive medicine and social medi¬ cine and clinical medicine. The important point is that the definition is a functional one. The student learns about the "real world" of medi¬ cine by having personal confrontation with its health problems, individual and group, in the community. Hence, the choice of the term "Community Medicine". Teaching Program The major objective of the
Department of has been teach a clini¬ Medicine to Community cal approach to the identification and solution
Canad. Med. Ass. J.
Sept. 16, 1967, vol. 97
of health problems of population groups or com¬
munities. To carry out this objective, a Faculty equipped to teach and conduct research at the clinical, laboratory, epidemiologic and public health levels has been recruited. Currently the professional staff consists of three internists, two
pediatricians, two general practitioners, one medical social worker and one medical anthropologist. There are four laboratories: mycology, tuberculosis, virology, and genetics. In addition, we are developing the "field professor" idea which will be mentioned later in this paper. The curriculum taught by our department, which all students are required to take, consists of a 72-hour course in the sophomore year and a six-week Kentucky community clerkship in the senior year. The sophomore course is comprised of a three-hour session held once a week for 24 weeks; it emphasizes epidemiologic principles and methods in both infectious and chronic dis¬ ease problems, using a combined lecture-seminar approach. Senior Clerkship The senior clerkship places every senior stu¬ dent for six weeks in a Kentucky community, throughout the state, the locus varying from urban to rural, north to south, east to west. He is assigned to work with a physician. However, the student is not in an orthodox preceptor relation¬ ship with that physician but rather is assigned through him to study the total health of the
community. This includes a variety of interrelated tasks. The student observes the practice of medicine, how medical records are kept, how the physician investigates patients and refers them. He has the opportunity to compare the pattern of disease as seen by the health depart¬ ment. He contrasts the disease problems in the community with that in the university hospital. He observes the functioning of the local medi¬ cal society and how physicians cope with the problem of continuing medical education. He observes for the first time the way a community hospital is organized, financed and managed. He learns about the local health department and its activities, including the functions of the public health nurse, the sanitarian, the health educator, etc. He attends meetings where health is a mat¬ ter of concern to voluntary agencies and local citizens' clubs. He visits local industries and in¬ vestigates occupational health problems. He confers with community leaders who have even a peripheral concern with health; thus most health personnel are included. In order to carry out this task the students use a fourfold approach: (1) they "work-up" individual patients in the physicians' office prac-
Canad. Med. Ass. J.
Medical Education 727
Sept. 16, 1967, vol. 97
tices; (2) they conduct a number of family studies in the home to observe the relationship
of the immediate environment to health and dis¬ problems; (3) they utilize a guide prepared by expert committee of the World Health Organization and modified by us which outlines how to study the health of a local community; and (4) they conduct an epidemiological study on some particular disease or health problem in the community. These studies may be modest, but they serve to emphasize the scientific ap¬ ease an
proach in attempting to answer a specific ques¬ tion or questions about a community health problem. In so doing, the student develops an appropriate design, obtains a proper sample if possible, and conducts the study, which may re¬ quire physical examinations or simple field tests, such as tuberculin testing or vitalometry. Finally, he writes up all of this material and presents it before his colleagues and the faculty during a seminar week. In order to emphasize the appropriate ap¬ proach to his community studies, each student is visited by a full-time faculty member from our department at least once a week while in the community. Thus there is a teaching-learning triad: student, local physician, and community medicine faculty member. The locus, then, of the teaching activity of community medicine is in the community out¬ side the hospital walls. By developing a compre¬ hensive report on the local health situation, studying a variety of community medical prob¬ lems, and conducting epidemiologic projects, the students and the faculty collect much use¬ ful information about the community. Many contributions have already been made to state and local health departments as well as other interested medical groups and voluntary health agencies; some of these studies have been published.3"6 Another important benefit has been the oppor¬ tunity for Kentucky communities to become with the upcoming medical gradu¬ acquainted ates of their state university. As taxpayers they have been committing funds to the development of the medical centre; now they may see the embryo physician just months or weeks before he receives his degree. Some communities have "courted" the medical student, offering him inducements to practise there. By the same token the medical students have had their eyes opened to opportunities of family practice and public health in a way that they could never have ex¬ They have de¬ perienced at the medicalforcentre. the a new physi¬ practising respect veloped cian and for the importance of public health in the
community.
It may be asked how the students learn good medicine in an outlying community when the model could be a horse-and-buggy approach from a bygone era. How can good habits be derived from seeing the operation of a decrepit health department and an overworked general practitioner in a setting of poverty in the midst of Appalachia? The answer is that a sick com¬ munity, implying stunted health resources in the face of tremendous medical need, is to be diag¬ nosed by the student, just as a sick patient is at the bedside. The more acute or chronic the ill¬ ness, the greater the potential challenge for the community-minded student. He attempts to pro¬ pose solutions to some of these problems as if he were in a position to do so. True, some stu¬ dents are depressed by what they observe. But we are convinced that the educational process is enhanced by such exposure so long as our
supervision
is
optimal.
The medical students in some respects have the ability to promote developmental change in the health area. In asking pointed questions about health services and unmet medical needs they have precipitated discussion and action in the community after departing. They might be looked upon as "change agents" in a kind of university medical centre extension-service program.
This does
not mean
ately placed practised poorly.
that students
are
deliber¬
in situations where medicine is
We select the local
physician-
supervisor with great care. We find that it takes a rotation or two for him to understand what our teaching program is striving to do, but we
have found
enthusiastic acceptance of the "field faculty". Each year we concept by have a meeting at the medical centre with the entire group, consisting now of about 100 physi¬ cians, during which we discuss the pros and cons of the program. They are quite positive about the worth of the program for them. Often it has acted as a stimulus for renewed interest in the medical centre as a state resource. The distribution of student assignments in such a given community does not have to absorb more than one student per year, except the urban areas where the syndrome of the "tired com¬ munity" (tired of students asking embarrassing questions) would not be anticipated to be as an
our
much of a potential problem. It should be men¬ tioned that most of the field faculty are family physicians, but the whole range of doctors, from the specialist in ophthalmology, surgery or in¬ ternal medicine to health officer or industrial physician, is represented. This may be the stu¬ dent's only opportunity to view the family phy¬ sician in situ. And, to reiterate, he often likes
728 Medical Education
the idea of what he sees, contrary to his university-hospital concept of the family physician. International Clerkship In addition to the community clerkship in Kentucky, our department offers an elective in international community medicine in an under¬ developed country.7- 8 In the fourth year, there is a 12-week elective period, and each student must elect to pursue some subject during this period. Our international clerkship has been offered each year that we have had senior stu¬ dents, so that this is now the fourth year of the program. Its aims are parallel to that of the In addition, it provides senior medical students with an opportunity to live in a community in a developing country. There, through participation in clinical, preven¬ tive and community medicine, he learns to ap¬
Kentucky clerkship.
preciate the country's overall health problems,
the many interrelated factors responsible for these problems, and the means by which they could be solved. The experience adds depth to the student's medical education which should be valuable in whatever type of practice he ulti¬ mately chooses. Interrelationships of economics, education, nu¬ trition and infectious disease may be obscured in the United States either because the problems have been partially solved or because of the great complexity of the relationships. In less de¬ veloped countries the implications of water sani¬ tation for health or the changes that could be expected from tuberculosis control, for example, can be immediately appreciated. In addition, the student sees medical care provided with many fewer resources than those to which he has been accustomed. It also challenges him to use his own ingenuity, a stimulus occurring less frequently here. In an area which has few or no accurate health statistics, he may have to collect his own. By this means he may attain better under¬ standing of the importance and value of such data, the methods by which they are ob¬ tained, their proper interpretation and their significance. In a foreign setting, surrounded by professionals and patients of a different culture, he gains a better understanding of humanity, learns to adapt, and in the shrinking world of today better equips himself for the future. How do we select the students for this pro¬ have had applications from gram? Thus far weclass. about half of each Early in the junior year we interview all of those who are interested. Then, based on a review of the students' records in medical school and intangibles such as atti¬
Canad. Med. Ass. J.
Sept. 16,1967, vol. 97
tude, character and motivation for the program, we attempt to select the best-qualified students. It is highly likely that a number of equally well-qualified candidates are not chosen, but
have the problem of numbers and some good students are therefore excluded. After choosing the group, we arrange for an introductory course in Spanish for those who are to go to Latin America. As yet, this has not been sufficient to enable them to speak fluently or well when they reach the foreign site, but it has provided a necessary basis upon which they have been amazingly successful in developing further skill while there. In addition, reading is assigned on the geography, history, politics, cul¬ ture, etc. of the area concerned. The blueprint for the clerkship is the same as for the Kentucky clerkship: that is, patient and family work-ups, community and epidemiologic studies under the immediate supervision of a faculty member of the foreign medical school, but with guidance by letter.infrequently by visit.from our staff. A prerequisite to the overseas clerkship is that the student must have taken the six-week clerk¬ ship in Kentucky first. Thus he should have de¬ veloped an ability to approach a community and to analyze it effectively. Administrative details such as the provision of immunization and visas are arranged through our department. These clerkships have been exciting and stimulating to the 35 students who have taken them. It is too early to say what has been their we
total medical educational value. Summer Fellowship During the past two years
we have developed large departmental summer fellowship pro¬ gram. In the summer of 1966, 45 students were involved in epidemiologic projects under the guidance of the faculty. Students from other a
medical schools and members of the incoming freshman class were included in the group. This program provides an extra stimulus by involv¬ ing students in community health studies early in their medical education. They learn applica¬ tion of epidemiological principles and biostatistical techniques, and are encouraged to produce papers of high quality at the conclu¬ sion of the program.
in Development There are a number of important challenges in further developing the teaching and research programs in community medicine. These include the new residency programs, the supervision of an expanding number of medical students, the
Programs
Medical Education 729
Canad. Med. Ass. J. Sept. 16, 1967, vol. 97
"field professorship" concept, and the of evaluation.
problem
Residency Programs An experimental community medicine resi¬ dency program was launched during the aca¬ demic year of 1964-65. A resident physician was given a series of both classroom and field assignments to enable the department to meas¬ ure what might be most valid for a formal residency program. The new residency is aimed at developing individuals who might become faculty members in departments of community medicine. This program has been officially ap¬ our first four residents are in proved. Currently training. As a measure of future interest, we have received applications from five members of last year's graduating class. A family practice program is being developed by the Department of Internal Medicine in collaboration with the Departments of Com¬ munity Medicine, Pediatrics and Psychiatry. Family-practice residents will be rotated through a considerable period in community medicine.
Logistical Problem A major problem in teaching community time involved in
medicine is the supervising students in the field. Although almost two-thirds of the state's population can be reached from Lexington by automobile within two hours, there are many interesting communities in the furthermost reaches of eastern Kentucky and the state which throughout the western half of With arduous improved trips. require long, roads, travel time has been reduced significantly. Moreover, there is an increasing number of airports throughout the state which permit travel by air. Nevertheless, the problem of time used
travelling is an important one. This is compounded by the increasing studentfacuity ratio. The32first seniorbutclassthe (1963-64) field pro¬ consisted of only students, full with a now is complement operating gram of 75. Expanding the entering medical student classes from 75 to 100 per year is being con¬ sidered. To insure close supervision from the experi¬ faculty for the "community experiences", ments have begun testing the concept of the "field professorship". Currently two people who hold academic positions in the department conduct teaching, research and service programs in
in their local communities.
Field Community Medicine
Professorships
A unique community-teaching research pro¬ gram was recently established in Madisonville,
Kentucky. Here, under the sponsorship of a private practice group, the state Health De¬ partment, and the Department of Community Medicine, a field Community Medicine Pro¬ fessorship has been set up. The physician who occupies this position serves as health officer, clinical epidemiologist, and participant in private group practice. In his combined role he makes the community population accessible to medical students and to residents in Community Medicine. A continuous study of the population is thus assured and fresh ideas for solving com¬ munity health problems are anticipated. Such field faculty can obtain expert consultation from the faculty in Community Medicine as well as from the staff of the entire medical centre. Academic, private and public health medicine are thus amalgamated. Over the next five years it is anticipated that there will be one field faculty professorship for each 20-county area (Kentucky has 120 counties). A second community medicine professorship has been established in conjunction with a com¬ munity college in Somerset, Kentucky. The phy¬
sician in this role teaches students sent to that
and co-ordinates the academic department with those of the practice of medicine and the health de¬ partment in the community. He is currently developing an academic program for health technicians who would serve as "all-purpose" aids for family physicians. The field professor may be viewed in the same light as, perhaps, the medical educator in the community hospital. The latter program is often directed by an internist or pediatrician who supervises the internship and the residency program, makes continuing-education programs available and in general conducts the teaching and research programs for the community hos¬ field professorship, the pital. In the case of theserve as the community area may 20-county the which in professor would laboratory maximize teaching and research opportunities, medical centre and its providing a liaison to the resources for teaching, research and service.
.area
for their
activities of
clerkship,
our
Evaluation One of the most difficult problems has been to develop effective mechanisms for evaluation to determine what effect the teaching program has had on education, attitudes and choice of career. At the start of the teaching experiment, enthusiastic acceptance by students, by the medical centre administration and faculty was deemed the most obvious and vital guide to success of the program.
730 MEDICAL EDUCATION
The second- and fourth-year students are questioned after they take the courses, to solicit constructive criticism and check their attitudes, skills and ability to consider broad problems in epidemiology, public health and medical care. We have used the videotape method in our attempts at evaluation wherein the senior students review their experiences in the community clerkship at the conclusion of the six-week period. These -have generally been helpful in pointing out the strengths and weaknesses of the structure of the program. These of necessity are quality appraisals only. Ultimately we will want to survey our graduates five and ten years hence, although-alas!-we have no control group. In attempting to evaluate our international clerkship we have employed both the depth interview and the "before-and-after" structured questionnaire technique. Both have value;
S. Med. Canad. vl.97 Sep.6, 96,Ass.
neither tells us what we ought to know, but this will have to await the passage of several years. We must admit that our efforts at evaluation leave much to be desired; we do endeavour to keep a critical attitude toward how we are attempting to carry out our program and thus to remain flexible as we plan for the future. REFERENCES 1. DEUSCHLE, K. W. AND FULMER, H. S.: J. Med. Educ., 37: 434, 1962. 2. DEUSCHLE, K. W. et al.: Milbank Mem. Fund Quart., 44: 9, 1966. 3. SLUSHER, M. M. AND KEENEY, A. H.: J. Kentucky Med. Ass., 63: 428, 1965. 4. POINTS, G. L., II, JONES, H. C. AND MCNAMARA, M. J.: Ibid., 64: 231, 1966. 5. OSGOOD, K., HOCHSTRASSER, D. L. AND DEUSCHLE, K. W.: Arch. Environ. Health (Chicago), 12: 759, 1966. 6. MoSs, K. G., FULMER, H. S. AND DEUSCHLE, K. W.: Ibid., 14: 407, 1967. 7. FULMER, H. S., ADAMS, A. C. I. AND DEUSCHLE, K. W.: J. Med. Educ., 38: 920, 1963. 8. ADAMS, A. C. I., Arch. Environ. Health (Chicago), 10: 95, 1965.
Community Medicine-A Commentary on the Discussion V. L. MATTHEWS, M.D., D.P.H.,* Saskatoon, Sask. THE participants at the Second Western Conference on Medical Education reached a surprising degree of agreement about the definition of the term "community medicine" and its value. Most felt that this term referred to the diagnosis of community health using epidemiological methods, with particular reference to social and other factors. Major emphasis was placed on changing or developing the student's attitude towards the community, the place of the practice of medicine in the community, and the interrelationships between all health workers in the community. A few definitely disagreed with this concept, favouring instead the use of this term to designate the demonstration and study of the relationship of community and social factors to individual illness. Community medicine also stresses the realities of practice in a community, thereby emphasizing that perhaps 'some of the things we do and teach in medical schools today are not really related to what physicians do when they practise in the community. To some extent community medicine has an interdisciplinary dimension as well. A synonym used by many for this complex and obviously heterogeneous area of medicine is "comprehensive care", provided that it involves the total needs of the family, as well as the individual. on Medical Presented at the Second Western Conference1966. Education, Vancouver, B.C., December 5-7. Prevenand Social of *Professor and Head, Department tive Medicine, University of Saskatchewan, Saskatoon.
In its most elementary form community medicine is a change in emphasis and a reorganization of public health. Translated into academic aims and curricular goals, this means the development in the student of an awareness of man and his environment. That environment includes the home, the family, the community and all the external environment which plays an important role in determining man's health. Community medicine, as we hope it will develop, should, in its overall approach, provide the student with some exposure to the social structure and social climate of the community, and should include a study of attitudes towards health as well as an exploration of how these attitudes differ from one community to another. More controversial, at least as a function of the medical school, is the exposure of the student to community health services organization. There was no general agreement among the participants at the conference about who should have the responsibility for teaching community medicine. A Department of Preventive Medicine or of Community Health, for example, could have the major responsibility for teaching community health to the student; others believe that such teaching should be a responsibility of each clinical department; while some consider that it could -be provided more effectively by a Department of General Practice. This area of conflict would also appear at the graduate level of education for general practice.
