Mapping Patient Distributions Informs Community-Oriented Primary Care in Four Community Health Centers in Central Massachusetts

Background Based on the philosophy that family medicine training should occur in community-based practices and hospitals, the Worcester Family Medicine Residency (WFMR) training program was structured to combine learning opportunities in an academic medical center with outpatient care training in three unique community-based practices: the Barre Family Health Center, a rural site thirty miles west of Worcester, the Family Health Center of Worcester, a federally funded community health center serving a poor and culturally diverse urban population, and the Hahnemann Family Health Center, a hospital-owned health center serving a socioeconomically diverse population in the northeast part of Worcester. The WFMR received an AAMC “Regional Medicine-Public Health Education Centers-Graduate Medical Education (RMPHEC-GME)” grant to further integrate public health training into the clinical training experience. As part of the effort, collaboration was begun between the department of Family Medicine and Community Health at UMASS Medical School, the academic home of the WFMR, and geographers at Clark University, a local resource providing expertise in mapping of data using Geographic Information Systems (GIS). Mapping Patient Distribution A series of thematic maps were generated from actual practice data on the patients being served by each residency site and also by Fitchburg Community Health Center. Faculty champions from each site attended two training sessions to learn more about the capabilities of mapping. They were then asked to lead faculty at their site in discussion to define five maps they would like to see made from their own patient data. Most sites chose a map showing the distribution of the entire patient population, some requested a map of their pediatric patients, and then the rest were designed to depict the spread of certain chronic diseases, including asthma, hypertension, coronary disease, and diabetes. Maps were generated using geocoding and point density tools in ArcGIS Desktop software. The main goal of this mapping activity was to educate physicians in training about where their patients live and facilitate discussion about environmental factors that impact health. These maps can also be used by practitioners to communicate important information to their patients about available community resources such as gyms, parks, health clinics, and supermarkets (as shown on some maps). Making Maps Available Online One element of the grant initiative was to build an online resource to aid faculty in teaching about population health concepts. This portal, the Community Health Toolkit (http://www.umassmed.edu/fmch/toolkit.aspx), provides three types of information to aid clinicians in both their teaching and their practice. The “Data on Communities” section was developed as part of the UMMS/Clark University collaboration. In total, 24 thematic maps were generated by the GIS team at Clark University and uploaded to the “Data on Communities” web section of the Community Health Toolkit. Other sections of the Community Health Toolkit include “Learning about Populations” which provides links to a variety of local, regional and national health indicators, and a “Community Resources” section which provides links to community resources for patients. The Toolkit is presented to learners along the continuum of medical education, including second year students in the Population Health Clerkship, first year residents in the Family Medicine and Community Health rotation, then used as a resource by residents as they complete presentations and research projects

Multi-Disciplinary Experts Supporting Graduate Medical Education through Participation in COMPLETE Chart Rounds

Learning Objective: As a result of this presentation, attendees will learn skills that they can use to implement collaborative graduate medical education learning experiences using a community of multi-disciplinary professionals within their own institutions. Background: Inter-professional Chart Rounds were implemented to provide residents an opportunity to review and present patient cases utilizing “COMPLETE” guidelines developed by residency leadership as the result of a “Regional Medicine – Public Health Education Centers” grant. COMPLETE guidelines explicitly direct residents to include consideration of: - Context – Culture of context – who is the patient? - Outside Visitors/Resources – incorporate visitors/experts such as librarians, pharmacists and psychologists and utilize their resources - Mental Health – assess behavioral health aspects of the case - Population Perspective – address prevalence of the condition in the community - Learn From Others – consider specialists, home care, and complementary therapies - Expectations – clear goals set between physician and patient - Time – Start on time, end on time. Respect everyone’s time. - End with “Culture of Continuity” – what are the key lessons? Is there a follow-up plan? Through the attendance of librarians, psychologists, pharmacologists, medical students and other faculty, discussion ensues which leads to continued resident education and support. Methods: Chart Rounds are held daily at each residency practice site. Residents are required to attend along with medical and pharmacy students rotating at the centers. The preceptor leads Chart Rounds and other faculty physicians join as they are able. Residents present cases while maintaining patient confidentiality. The preceptor leads the group discussion of the case. Faculty members discuss clinical and administrative implications, the psychologist addresses potential behavioral aspects of the case, the librarian searches for Evidence-Based information to support decisions and the pharmacologist advises on medication management. The group also discusses how individual patient care reflects the public health needs and profile of the community. Residents (n=32) were invited to complete a survey asking them to evaluate their experience with multi-disciplinary COMPLETE Chart Rounds. Results: Survey results as well as observational analysis will be used to improve the resident’s experience at Chart Rounds with the goal of making this experience an even more rewarding collaborative educational experience. Some sample findings include: - 66% of residents report satisfaction of Chart Rounds challenging the academic aspects of their work - 100% of residents in the early portion of their program report that Chart Rounds assists them in building collaborative relationships with faculty and other providers/experts - Residents report the greatest satisfaction (92% overall) with pharmacist participation in Chart Rounds across all Post Graduate Years - Satisfaction with librarian participation increases through each year (from only 10% in PGY1 to over 60% in PGY3) , possibly due to limited exposure early in the program Although these guidelines were developed for use in a Family Medicine Graduate Medical Education program and fit well into this practice model, the findings can be utilized in other resident training programs. Presented at the Patients and Populations: Public Health in Medical Education conference sponsored by the Association of American Medical Colleges (AAMC) and the Centers for Disease Control and Prevention (CDC), held September 14-15, 2010, in Cleveland, OH

Care that Matters: Quality Measurement and Health Care

Barry Saver and colleagues caution against the use of process and performance metrics as health care quality measures in the United States

A Beta Test of a Computer-Assisted Instruction Module in Improving Dermatologic Physical Exam Skills in Third Year Medical Students

Introduction: Third year medical students at UMass. Medical School have only a brief exposure to dermatology during their first two years, resulting in limited skills in dermatology physical diagnosis. While other skills of the physical exam – e.g. the cardiac exam, the abdominal exam – are taught in the first 2 years and are applied and refined with repetition and instruction during students’ clinical rotations, dermatology remains limited in its exposure and instruction during the third year. This may prevent students from gaining the needed physical diagnosis skills in this important clinical area. Given this scenario, a computer-assisted instruction module was created and beta-tested to improve students’ physical diagnosis skills in dermatology. Method:A computer-based dermatology physical diagnosis presentation was created using Microsoft PowerPoint to instruct third year medical students in dermatology physical exam skills. Each slide presented students with a dermatology physical exam finding, a brief description, and a picture. In order to test the students’ knowledge of dermatology physical exam findings, a 23-item multiple-choice exam was created using XCom Exam Composer. 9 questions dealt with knowledge of verbal descriptions of lesions, while 14 questions dealt with the identification of lesions. The test was administered both before and after the presentation to 15 students taking a required 6-week Family Medicine clerkship at UMass. Medical School. Results:13 out of the 15 sampled students completed the curriculum. The average pre-test score was 18.4/23 questions correct (80%); the average post-test score was 20.5/23 questions correct (89.1%) - with an average improvement of 2.1 points (9.1%). These results (i.e., the increase in scores post-test) were statistically significant using both a parametric paired t-test (t = 2.720; p=.019) as well as a non-parametric Wilcoxon Signed Ranks Test to take the small sample size into account (z = 2.508; p=.012). Discussion: This computer-assisted instruction in dermatology significantly improved students’ physical exam skills, as measured by this multiple-choice exam. Informal comments were positive: students enjoyed the module, and appreciated the increased exposure to dermatology. Future studies are needed to evaluate student experience during this module, as well as their competence and confidence in diagnosing dermatologic lesions. Also, the Family Medicine Clerkship faculty intends to evaluate this module with a larger population of students, including those at different stages of their third year medical training, in order to examine the module’s effects. Furthermore, studies using a larger population are needed to evaluate the benefit and cost-effectiveness of this computer-assisted instruction program versus traditional book-based instruction

Weaving public health education into the fabric of a family medicine residency

Policymakers and accrediting bodies have recognized the importance of integrating public health, population health, and prevention into graduate medical education programs. The high prevalence of chronic illness, coupled with the impact of behavioral and societal determinants of health, necessitate an urgent call for family medicine residencies to prepare future leaders to meet these challenges. The University of Massachusetts Worcester Family Medicine Residency recently developed an integrated curriculum that strives to develop a culture of incorporating fundamental public health principles into everyday practice. This public health curriculum was designed to integrate new topics within the current residency structure through longitudinal and concentrated experiences. This strategy has substantially improved public health and prevention education without substantial impact on the already strained residency curricular structure. This paper describes the integration of public health and prevention education into a family medicine residency to help residents acquire the fundamental skills necessary to improve a population\u27s health. Inc. All rights reserved

Comparison of typical performance measures and author recommendations.

<p>* NNT: number needed to treat; NNH: number needed to harm; NNS: number needed to screen</p><p>Comparison of typical performance measures and author recommendations.</p