AAMC Reporter: May 2008

A Community Approach to Resident Training and Patient Care

"The idea is that residents can learn how medical practitioners integrate with these communities through churches, schools, public health professionals, and other avenues." —Julie A. Dostal, M.D., residency program director, Lehigh Valley Hospital and Health Network

There is a saying that all politics is local. Maybe the same principle holds true for health.

There is no question that the community in which a person lives and works has a considerable influence on the lifestyles and health of its residents. So it stands to reason that improving a doctor's expertise in community-based medicine could lead to significant improvement in health problems that span a specific geographic region. Several programs currently training resident physicians have been restructured to better train tomorrow's doctors to seek out and study community-wide health problems—and take a community-wide approach to their solutions.

These programs emphasize the idea that a keen understanding of patient populations is necessary for a healthy community. Also important is a philosophy of team-oriented care that includes collaboration with public health experts and awareness of community resources. By placing residents in area practices, the programs allow trainees to hone their own skills and encourage other physicians to adopt these new protocols in order to provide better community-based care.

The Hendersonville Family Practice Residency Program in Hendersonville, N.C.; and the Lehigh Valley Hospital and Health Network's Family Medicine Program in Allentown, Pa., began revamping their curricula last July. Both are participants in Preparing the Personal Physician for Practice (also known as P4), an American Academy of Family Physicians (AAFP) initiative meant to foster innovation in family medicine residency programs.

Lehigh Valley's curriculum eliminated first-year rotations. Instead, trainees now alternate between a three week stint in a family health center and three weeks in the hospital setting.

Didactic activities during the health center block teach residents to take a multifaceted approach when addressing common health problems, such as diabetes or other chronic diseases. These include instruction in health disparities and collaboration with different health care team players when providing care.

"Diabetes management, for example, is not only about taking medication," said Julie A. Dostal, M.D., Lehigh's family medicine residency director. "There are a lot of psychosocial factors that can affect outcomes. Other health professionals may have these insights."

In the revamped curriculum, residents customize their education to focus on a particular area of family medicine, usually within some community context, during their last two training years. For instance, Dostal said, one resident interested in free clinics spent time training in these facilities. Another trainee examined how to improve diabetes education and self-management.

Starting in July 2008, Lehigh residents will train with family medicine doctors in local family practices that are being redesigned to emphasize team-oriented, patient centered care. This change, Dostal said, will allow residents to apply what they learned in their didactic sessions and be agents of change in these practices.

"The idea is that residents can learn how medical practitioners integrate with these communities through churches, schools, public health professionals, and other avenues,"Dostal said.

Hendersonville has a slightly more specific mission—to prepare residents to practice in rural communities. Rural areas have specialized health concerns, such as higher rates of agriculture-related injuries and fewer resources than their urban counterparts. For their clinical practice component, residents train at one of three rural practices. This training, said Associate Program Director Geoffrey L. Jones, M.D., helps residents gain experience and expertise practicing in communities with limited resources.

"At these clinics, someone may come in with a finger cut off, and the resident has to repair it," Jones said. "At larger places, the patient would go to an emergency room, but here there is no emergency room."

Technology also can mitigate the negative effects of having minimal local health services. Residents at all three clinics learn to use electronic health record systems to consult with other health professionals.

Other phases of training take place at the Hendersonville Family Health Center. The newly redesigned center has no waiting room or front desk; nearly every task—examining patients, handling bills, and faxing prescriptions to pharmacies—is performed by the doctor and nurse. A greeter meets patients in the lobby and escorts them to their room. Advanced technology allows providers to access and update charts.

Moving forward, Jones said Hendersonville hopes to install these new models in three community clinics,with residents being an instrumental part of this transition.

Another part of the new curriculum is a two-year community health project. Residents will choose a particular public health issue and design a project that addresses it. Eric Chen, M.D., a first-year resident, plans to create a pilot mental health court program, which would allow mentally ill criminal offenders to avoid incarceration if they comply with treatment protocols.

"This would be a win-win," he said. "Criminal offenders don't get sent to jail, and the [local government] doesn't have to pay for them to go through the courts." (Government monies, however, might pay for the mental health services.)

These projects, Jones said, will let residents make a positive community change.

"These projects make residents start thinking about things specific to a particular area," Jones said. "Then, through a specifically designed intervention, residents can advocate for the community."

—By Elissa Fuchs

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