Primary Care Curriculum Research Articles

Operationalizing a 3-year standalone, accelerated medical school curriculum to nurture physicians to become primary care and health system leaders

The United States faces a shortage of primary care physicians. To address this, there have been pioneering efforts to develop accelerated pathways with a primary care focused curriculum for undergraduate medical education. The New York University Grossman Long Island School of Medicine (NYU GLISOM) was conceptualized as the first standalone, accelerated, tuition-free program in the US in over 100 years, with mission-centered curriculum on primary care and health system leadership. The aim of this article is to map the process for the development of a three-year integrated curriculum, describe the pedagogical approach that guided the design of the longitudinal courses, share the student and faculty’s perspective about the curriculum, and describe the early outcomes of the first two graduate classes. A major key driver for curricular design is integrating longitudinal courses of Clinical Ambulatory Practice Experience (CAPE), Health Systems Science (HSS), and Learning Community - Social Sciences, Humanities, Ethics and Professionalism (LC-SHEP) over three years and active learning through Problem Based Learning (PBL). We have successfully operationalized an accelerated, standalone, integrated medical school curriculum mission-centered on primary care and health system leadership. Our outcomes reveal a higher percentage (76% N =45) of NYU GLISOM students entering primary care compared to national benchmarks. The integration of the longitudinal courses of HSS, LC-SHEP, and CAPE is a key pillar to reinforce the tenants of primary care and health system leadership. Focused interview of graduates from the pioneer cohort consistently stated that the longitudinal courses prepared them well for residency in primary care and as a health systems’ change agent. Despite the challenges of an accelerated program, NYU GLISOM successfully integrated the longitudinal courses with optimal performance and achievement of educational program objectives. Our experience can serve as a model for innovation and design of an accelerated three-year primary care curriculum.

No education without feedback: why and how to give it in the clinical setting

The number of medical students and doctors in training is growing, particularly in private practices due to the promotion of the internal medicine and primary care curriculum. Therefore, doctors increasingly find themselves in a teaching role with the responsibility to give feedback to the people in training. This article aims to give the definition of feedback and to review the reasons for its central role in pre- and postgraduate medical education. We describe the opportunities and barriers to giving feedback, how to make it effective and present a selection of frequently used feedback models.

Use of the World Health Organization primary eye care protocol to investigate the ocular health status of school children in Rwanda

To assess the ocular health status of primary and secondary schoolchildren in Rwanda and to explore the use of the World Health Organization (WHO) primary eye care screening protocol. This was a cross-sectional population-based study across 19 schools in Rwanda. Initial screening was carried out using the WHO screening protocol, whereby visual acuity was measured using a tumbling E Snellen chart (6/60 and 6/12). Abnormal ocular features were identified using a flashlight and history against a checklist. All children with abnormal screening were referred to an on-site ophthalmic clinic for full examination. Those who could not be treated on-site were referred to an ophthalmologist at a hospital for specialist care. A total of 24,892 children underwent ocular health screening. Of those, 1,865 (7.5%) failed the primary screening; 658 (2.6%) were false positives (35.3% of those who failed screening), and 1,207 (4.8%) true positives. The most frequently observed ocular diagnoses were allergic conjunctivitis (3.11%) and strabismus (0.26%). Refractive error was very rare (0.18%). The WHO primary eye care curriculum provides existing health personnel with an approach to school-based vision screening that uses a standardized checklist and low-cost resources. In our study cohort, results indicated a low frequency of refractive error; the overwhelming majority of ocular problems could be identified on visual inspection.

Development of Objectives to Inform a National Standardized Primary Palliative Care Curriculum for Health Professions Students.

Introduction: Despite recent educational advances, the need for a national standardized primary palliative care curriculum for health professions students remains evident. Methods: An interprofessional leadership team developed a set of core learning objectives built on previously published competencies. A survey was then sent to palliative care experts for feedback and consensus. Results: Twenty-eight of 31 objectives met a 75% consensus threshold, 2 were combined with others, and 12 were refined based on survey feedback. Discussion: With interprofessional input at all stages, we finalized a comprehensive list of 26 learning objectives for a primary palliative care curriculum targeting health professions students. These objectives will be widely available through an online course but can also be adopted for use by individual educators across health professions institutions. These objectives and related curriculum are critical to producing practice-ready clinicians who are prepared to care for the burgeoning population of seriously ill patients.

Development of a list of core clinical topics suitable for a shared primary care curriculum for medical undergraduates in Malaysia: A Delphi study

ABSTRACT In the last few decades, primary care medicine (PCM) is increasingly recognised as a cornerstone of an efficient and effective healthcare system. However, the PCM discipline is now facing challenges such as a shortage of doctors. One of the possible reasons could be the lack of comprehensive PCM curricular components in the undergraduate medical programmes. This study aimed to develop a list of core clinical topics suitable to be used as a shared PCM curriculum for undergraduate education in Malaysia. A Delphi survey that consisted of three iterative rounds with feedback was used in this research. The participants included PCM experts involved in the undergraduate level of PCM teaching. These experts were selected based on the criteria developed by two senior academicians in PCM medical education. The final developed list contained 34 core clinical topics that should be incorporated into the undergraduate PCM curriculum. The findings will be useful in establishing the policies and guidelines of PCM education for undergraduates in various medical schools. This study may also promote the field of PCM and encourage more doctors to take up the speciality. Lastly, it provides essential information to address the knowledge gap in PCM education among undergraduate medical students in Malaysia.

An Interprofessional Primary Palliative Care Curriculum for Health Care Trainees and Practicing Clinicians.

Background:Equipping all interprofessional clinicians with foundational palliative care competencies is essential to address the complex needs of the growing number of adults living with chronic, progressive, or life-threatening serious illness. There is a paucity of high-quality, open-access primary palliative care curricula and to the best of our knowledge, none designed interprofessionally.Objective:As an interprofessional team, we aimed at designing and evaluating an interactive primary palliative care education curriculum for interprofessional clinicians and trainees.Design:We developed a curriculum that includes nine 55-minute interactive modules facilitated by two interprofessional clinicians in small groups of 8–12 interprofessional learners.Setting/Subjects:Thirty-two practicing interprofessional clinicians from the San Francisco Bay Area enrolled in the pilot.Measurements:Pilot curriculum evaluation included electronic surveys pre- and post-module and at completion of the full curriculum.Results:The final evaluation response rate was 44%. Ninety-three percent of survey respondents rated the curriculum's quality as “very good” or “excellent”; 86% of respondents felt the curriculum was “extremely” or “very useful” to their clinical practice. Comparing pre- and post-module survey data, statistically significant (p < 0.01) improvements in learner confidence were seen for each of the 25 curriculum learning objectives with an average improvement of 2.8 points.Conclusions:The curriculum was well received and was associated with an increase in learner confidence. This novel, flexible, and tuition-free curriculum fills an important educational gap and can be used to equip frontline, interprofessional clinicians with the core palliative care knowledge, skills, and attitudes to take the best possible care of seriously ill patients and families.

An Interactive Workshop on Managing Dysphagia in Older Adults With Dementia.

IntroductionNearly six million American adults live with dementia, and dysphagia is a common comorbidity impacting their nutrition and quality of life. There is a shortfall in the number of geriatricians available to care for older adults. Thus, primary care physicians should be equipped with the knowledge to adequately care for the geriatric population. Modified diets are routinely prescribed for patients with dementia despite limited evidence that they protect patients from the sequelae of dysphagia and some suggestion of poor side-effect profiles.MethodsWe created a onetime, interactive, case-based session to educate medical residents on how to evaluate and treat dementia-associated dysphagia and address the discrepancy between the limited evidence for dietary modifications and their routine use. The session had a mixture of small-group discussion and didactic learning as well as a participatory component during which learners were able to sample thickened liquids.ResultsThe session was implemented in an established primary care curriculum. Based on survey responses, which were obtained from 15 out of 17 participants, the session significantly improved participants’ knowledge of dysphagia-associated dementia and increased their comfort with caring for patients with dysphagia.DiscussionDementia-associated dysphagia, although an increasingly common clinical problem, remains an underexamined area of medicine. We successfully implemented a session on this topic for internal medicine residents on the primary care track. Limitations included generalizability due to the small number of residents in the course and inability to gather sufficient data to see if knowledge learned was sustained over time.

Improved oral health knowledge in a primary care pediatric nurse practitioner program.

Pediatric nurse practitioners (PNPs) are a significant workforce in primary care and are uniquely positioned to improve oral health in children through ongoing surveillance in the well-child visit. The purpose of this study was to evaluate PNP student satisfaction and knowledge gained with the integration of the Strategic Partnership for Interprofessional Collaborative Education in Pediatric Dentistry (SPICE-PD) oral health education program into the first-year primary care curriculum. A descriptive, comparative design examined dental test scores across the pre-SPICE-PD (2013-2014; n = 26) and post-SPICE-PD (2015-2020; n = 55) cohorts. An electronic survey was completed (n = 47; 67%), and focus group (n = 12) audio-recordings were analyzed using Atlas.ti 8.0. Chi-square test and independent samples t-test were used to assess differences between groups. The SPICE-PD students reported improved knowledge and skill in clinical practice. Focus group themes were oral health education was beneficial, impact of coronavirus disease 2019, and suggestions for improvement. Mean dental test scores improved pre- and post-SPICE-PD (83 vs. 93; p < .001). The SPICE-PD oral health education improved knowledge and was highly satisfying for students. Pediatric nurse practitioners are ideally positioned to integrate oral health into primary care services, thereby improving access to care and ultimately reducing or mitigating early childhood caries. Evaluation of PNP postgraduation practices in the primary care setting is needed to assess whether improved knowledge results in practice change.

Change that Matters: A Health Behavior Change and Behavioral Health Curriculum for Primary Care.

Although primary care is an ideal setting in which to address behavioral influences on health, clinicians spend little time discussing preventive care, including lifestyle counseling. There is a dearth of comprehensive training and evidence-based resources to educate clinicians in how to effectively engage with patients about these topics. This study describes and evaluates the acceptability of Change that Matters: Promoting HealthyBehaviors, a ten-module curriculum to train clinicians in brief, evidence-based interventions. Each module includes three parts: interactive patient handouts, didactic training, and electronic health record templates to guide the discussion and after visit summary. A two-part, mixed-methods pilot study was used to evaluate the acceptability of the curriculum in a family medicine residency clinic. In Study 1, external family medicine faculty experts (N = 11) provided written feedback on the patient handouts. In Study 2, 20 residents and 20 patients completed qualitative interviews regarding their experience with curricular materials. Content analysis was used to extract qualitative themes. Experts rated the patient handouts as highly understandable and actionable. Resident themes indicated that the curriculum provided concrete tools to address health behavior change, helped structure patient discussions, and increased confidence. Patients felt empowered to make behavior changes. This new curriculum addresses a gap in existing resources, and is available for free download online which can facilitate dissemination( https://changethatmatters.umn.edu/ ). Research has found the curriculum to be acceptable to experts, residents, and patients. Future studies need to explore its impact on the behavior of both clinicians and patients.

Dermoscopic Lotus of Learning: Implementation and Dissemination of a Multimodal Dermoscopy Curriculum for Primary Care.

Dermoscopy is a cost-effective tool for detection of skin cancers yet there is limited training available for primary care. The goal of this project was to develop, implement, and disseminate a multimodal curriculum for primary care across a health system based on a previously validated algorithm (Triage Amalgamated Dermoscopic Algorithm; TADA). This cross-sectional study analyzes the dermoscopy workshop intervention of a dermoscopy multimodal curriculum. Volunteers attended one 120-minute dermoscopy workshop on benign and malignant growths using a validated algorithm. Participants took a 30-image pre- and posttest. Survey questions on dermoscopy use, preferences for learning, and skin biopsy performance were included to enhance curriculum development. About 96 participants completed both pre- and postintervention tests. The mean preintervention score (out of 30) was 18.6 and increased to 24.4 on the postintervention evaluation. There was a statistically significant improvement in scores for both benign and malignant skin growths after the intervention (P < .05). Short dermoscopy workshops have a positive intervention effect when training primary care providers to identify images of benign and malignant dermoscopic skin lesions. A multimodal dermoscopy curriculum allows learners to build on initial training using spaced review and blended learning strategies. The “Dermoscopic Lotus of Learning” has the potential to be a model for other primary care residency programs. A healthy partnership between dermatologists and primary care is essential.

A National Perspective on the Current Educational Environment in Pediatric Community-Based Continuity Clinic.

To characterize current practices of US pediatric residency programs around use of community-based continuity clinics for residency training. A national, anonymous survey was sent electronically to all US pediatric program directors (PDs) through the Association of Pediatric Program Directors (APPD). The survey assessed preceptor recruitment, faculty development, teaching methods, and PDs' satisfaction with the experience and teaching at community sites. Data were analyzed using descriptive statistics and Chi2 Test of Independence. A total of 99 of 200 (50%) programs responded. Fifty-six percent (55/99) did not sent any residents into the community. Of the remaining 44 programs, 48% had difficulty recruiting preceptors. Only 34% require preceptors to engage in faculty development around teaching and less than half require community preceptors to work through a formal curriculum. Almost all PDs that sent residents to community-based practices were very to extremely satisfied with resident experiences (84%), but 37% were not satisfied with residents having their own patient panel. While the majority of PD's were satisfied with resident experiences in community-based sites, recruitment was challenging, and teaching and faculty development methods varied. Determining incentives to help recruitment, ensuring use of a formal primary care curriculum and providing faculty development around teaching, will be critical for training.

Social prescribing by students: the design and delivery of a social prescribing scheme by medical students in general practice

ABSTRACT Background Social prescribing is a means of enabling primary care professionals to refer people to a range of local, non-clinical services. Medical students at a large GP surgery in Corby designed, implemented and led a social prescribing service for the practice’s patients. Through the project students gained an understanding of social prescribing in an authentic setting. Methods During a 12 week GP placement students collated information on local organisations, charities and schemes into a social prescribing directory. A clinic was set up and a social prescribing protocol created to enable suitable patients to be referred to the service. Students educated staff and collected feedback on how the service should run. Patients referred to the service were seen by medical students, who identified suitable social prescribing opportunities. Follow up was arranged to encourage patient engagement with services. The student-led service has been successfully integrated with the work of the new PCN link worker. Outcome Medical students were able successfully identify social prescribing opportunities for patients referred to them in primary care. Experential learning enabled them to develop an understanding of social prescribing and its place in healthcare. Discussion Medical students successfully designed and delivered a social prescribing intervention providing authentic educational experience in real-life clinical practice. The introduction of a Primary Care Network link worker enhanced this work and student input has continued in the ongoing service. It is hoped the scheme will be rolled out across the Primary Care curriculum in Leicester.

Implementation of TeamSTEPPS concept at an academic primary care clinic

Abstract Team Strategies and Tools to Enhance Performance and Patient Safety (TeamSTEPPS) is an evidence-based team building curriculum developed by the Department of Defense and the Agency for Healthcare Research and Quality (AHRQ). We utilized the TeamSTEPPS Primary Care curriculum to teach teamwork skills to all members of our primary care team, including frontline clerks, nursing staff, advanced practice providers, residents and faculty. All team members learned the same specific skills in leadership, communication, situation monitoring and mutual support which are essential for effective clinic team functioning. Additionally, team members from each of the different disciplines were given leadership roles. Since the implementation in 2013, we observed increases in staff job satisfaction, Press Ganey patient satisfaction scores, patient safety, resident perceptions of teamwork and teamwork culture.

Registered nurse education in primary care: Barriers and resolutions.

American health care is facing unprecedented challenges due to population aging, chronic disease prevalence, and financial restructuring. The Affordable Care Act (ACA) is transforming the primary care landscape from a reactive, episodic, fee-for-service system to a proactive, preventive, value-based system. A proactive, preventive, and value-based primary care model requires Registered Nurses (RNs) prepared to lead integrated, team-based, coordinated, and proactively managed care. The Health Resources and Service Administration (HRSA) forecasted an inadequate supply of RNs prepared to meet future primary care demands and highlighted the lack of education as a key problem. The primary care RN workforce shortage requires immediate attention by academic, political, and research stakeholders. HRSA has responded with academic funding to increase primary care RN education. This article describes key barriers and resolutions one HRSA-funded academic institution experienced while implementing a primary care RN education program, along with research implications for the future of primary care nursing. This article describes the project's stakeholder, faculty, and student engagement methods. This article also describes the clinic RN preceptor development program, and depicts the Primary Care RN Education Program Student Clinical Experience Preceptorship Model. Nursing education must align with transforming healthcare models while anticipating potential barriers and resolutions to enhancing curriculum with primary care nursing education and clinical experiences. This article provides insight for other academic institutions interested in developing primary care curriculum and academic-clinic partnership models to foster community-based primary care clinical experiences.

If You Build It, Will They Come? A Hard Lesson for Enthusiastic Medical Educators Developing a New Curriculum.

Primary care forms a critical part of pediatricians' practices, yet the most effective ways to teach primary care during residency are not known. We established a new primary care curriculum based on Malcolm Knowles' theory of andragogy, with brief clinical content that is easily accessible and available in different formats. We used Kern's model to create a curriculum. In 2013, we implemented weekly e-mails with links to materials on our learning management system, including moderators' curricular content, resident-developed quizzes, and podcasts. After 3 years, we evaluated the curriculum with resident focus groups, retrospective pre-/post-resident surveys, faculty feedback, a review of materials accessed, and resident attendance. From content analysis of focus groups we learned that residents found the curriculum beneficial, but it was not always possible to do the pre-work. The resident survey, with a response rate of 87% (71 of 82), showed that residents perceived improvement in 37 primary care clinical skills, with differences from 0.64 to 1.46 for scales 1-5 (P < .001 for all). Faculty feedback was positive regarding curriculum organization and structure, but patient care often precluded devoting time to discussing the curriculum. In other ways, our results were disappointing: 51% of residents did not access the curriculum materials, 51% did not open their e-mails, only 37% completed any of the quizzes, and they attended a weekly conference 46% of the time. Although residents accessed the curriculum less than expected, their self-assessments reflect perceptions of improvement in their clinical skills after implementation.

Status of Oral Health Training in U.S. Primary Care Programs: A Qualitative Study to Define Characteristics and Outcomes.

With increasing recognition of the important relationship between oral and systemic health, non-dental health professions schools and programs are now teaching their students about oral health in various ways. This study built on surveys of medical schools, primary care residency and fellowship programs, and other health professions programs conducted by the authors in 2017, which found some had made significant progress in integrating oral health into primary care training, while others lagged behind. The aim of the current study was to better understand the characteristics and climate of oral health education in non-dental health professions schools by conducting interviews with leaders of programs who had self-identified in the surveys as having a robust oral health curriculum. Hour-long interviews were conducted between October 2017 and March 2018 with 31 program directors or deans of medical specialty and allied health professions programs using a semi-structured interview guide. These interviewees were from 13 health disciplines. The coding of interview transcripts identified seven major themes: motivations to develop an oral health curriculum; rationale for curriculum topics covered; best aspects of the curriculum; evaluation and assessment strategies; relationships with dental providers and residents and dental hygienists; barriers and challenges; and advice and lessons learned. The interviewees reported a strong belief that oral health is an important health topic. Key elements that interviewees identified as helping them build robust oral health programs in their primary care curricula were the following: having an oral health champion; having some funding; building relationships with dental professionals; using local, state, and national resources; using curricular materials from existing sources; incorporating skills-based sessions; taking an IPE approach; and making oral health part of what the program already does. These findings should be useful for primary care schools and programs that are beginning to add oral health to their curricula and those seeking to improve their existing oral health education for their students.

School Health: Pediatric Primary Care Curriculum.

Pediatric residents encounter issues related to school health (SH) throughout their training, particularly in their continuity clinics, and often serve as liaisons between a patient's medical home and school environment. However, there is currently a paucity of formal education on SH for pediatric residents to prepare them for this role. We created a 3-hour interactive learning conference that was delivered to four groups of six to eight pediatric residents during their intern year by a multidisciplinary team. Our curriculum focused on understanding the differences between individualized educational plans (IEPs), individualized health plans (IHPs), and 504 plans; the IEP process; and communication with schools. Residents were given pre- and postdidactic surveys, completed reflective writings, and participated in feedback sessions. Twenty-seven pediatric interns completed the curriculum; 85% and 74% had improved knowledge of IEP/504/IHP and SH personnel, respectively. Eighty-five percent reported feeling comfortable with family conversations about accommodations postcurriculum versus 0% precurriculum. The majority of interns found the curriculum to be valuable to their clinic performance. Our curriculum offers a unique multidisciplinary approach to teaching and can be easily integrated into other residency programs, even with limited protected didactic time.

HIV Primary Care Curriculum Improves HIV Knowledge, Confidence and Attitudes

Abstract To meet the goals of the National HIV/AIDS Strategy and the need for a human immunodeficiency virus (HIV)-competent primary care workforce, education and training of nurse practitioners are critical. The University of California, San Francisco School of Nursing developed and implemented an HIV primary care curriculum and evaluated this curriculum for a graduating cohort of 55 students. Results show gains in students’ HIV knowledge and confidence in providing basic HIV care and improvements in attitudes toward people living with HIV. We have been able to show that HIV content can be successfully integrated into a nurse practitioner generalist curriculum.

How well are Swiss French physicians prepared for future practice in primary care?

BackgroundMoving from postgraduate training into independent practice represents a major transition in physicians’ professional life. Little is known about how Swiss primary care graduates experience such a transition. The aim of this study was to explore the extent to which primary care physicians who recently set up private practice felt prepared to work as independent practitioners.MethodsWe conducted 7 focus groups among recently established (≤ 5 years) primary care physicians in Switzerland. Questions focused on positive and negative aspects of setting up a practice, and degree of preparedness. Transcripts were analysed according to organisational socialisation and work role transition frameworks.ResultsParticipants felt relatively well prepared for most medical tasks except for some rheumatologic, minor traumatology, ENR, skin and psychiatric aspects. They felt unprepared for non clinical tasks such as office, insurance and medico-legal management issues and did not anticipate that the professional networking outside the hospital would be so important to their daily work. They faced dilemmas opposing professional values to the reality of practice which forced them to clarify their professional roles and expectations. Adjustment strategies were mainly informal.ConclusionAlthough the postgraduate primary care curriculum is longer in Switzerland than in most European countries, it remains insufficiently connected with the reality of transitioning into independent practice, especially regarding role development and management tasks. A greater proportion of postgraduate training, with special emphasis on these issues, should take place directly in primary care.

Blueprint for an Undergraduate Primary Care Curriculum.

In light of the increasing demand for primary care services and the changing scope of health care, it is important to consider how the principles of primary care are taught in medical school. While the majority of schools have increased students' exposure to primary care, they have not developed a standardized primary care curriculum for undergraduate medical education. In 2013, the authors convened a group of educators from primary care internal medicine, pediatrics, family medicine, and medicine-pediatrics, as well as five medical students to create a blueprint for a primary care curriculum that could be integrated into a longitudinal primary care experience spanning undergraduate medical education and delivered to all students regardless of their eventual career choice.The authors organized this blueprint into three domains: care management, specific areas of content expertise, and understanding the role of primary care in the health care system. Within each domain, they described specific curriculum content, including longitudinality, generalism, central responsibility for managing care, therapeutic alliance/communication, approach to acute and chronic care, wellness and prevention, mental and behavioral health, systems improvement, interprofessional training, and population health, as well as competencies that all medical students should attain by graduation.The proposed curriculum incorporates important core features of doctoring, which are often affirmed by all disciplines but owned by none. The authors argue that primary care educators are natural stewards of this curriculum content and can ensure that it complements and strengthens all aspects of undergraduate medical education.