Residency Training in Primary Care > FY 2005 Grant Summaries

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Alabama

D58HP05174
Allen Perkins, MD, MPH
University of South Alabama
Department of Family Medicine
1504 Springhill Ave
Mobile, AL  36604
Tel: 251-434-3482
Email: aperkins@jaguarl.usouthal.edu

This project offers a competing approach, where learners and graduates work together to acquire and maintain knowledge necessary for practice.  In addition to enhanced recruitment, we will focus on curriculum enhancement and relevance.  We will augment our behavioral science and practice management curriculums to include material and data reflective of actual practice needs as identified by graduates.  This will include training in screening for depression and integrative medicine.  The core conference curriculum will be reformulated to enable graduates to easily avail themselves of evidence based content changes and give them the opportunity to offer feedback based on practical experience.  Testing and CME will be introduced.

We believe that including graduates in the training milieu will improve residents' and graduates' skills and will increase the relevance of the training program.  To accomplish this, we wish to enhance instruction in practice management, train residents to screen for depression, and eliminate errors in the care of patient with serious mental illness based on a needs assessment of our current residents and graduates.  We wish to do this in such a way that we support and enhance the knowledge base and certain core skills of graduates as well.  In addition, we believe that if we create and maintain a clinical information resource based on our core conference curriculum and design a way for graduates to discuss this information with residents, our residents will be more likely to retain relevant information and graduates will be better able to maintain their core knowledge base.  We also wish to continue to recruit high quality minority students into our residency program.

Project Objectives:

1. Maintain our historically high minority enrollment by identifying recruits and encouraging them to participate in our training program;
2. Strengthen existing instruction in mental health by developing formal training in depression screening and polypharmacy instruction for patients with mental illness in the residents existing longitudinal curriculum and include interaction between residents and graduates to enhance experience and increase relevance;
3. Enhance the practice management curriculum by creating instructional models using the residents' practice information and develop enhanced instructional material for access to learners and graduates and include interaction between residents and graduates to enhance experience and increase relevance; and
4. Develop an improvement process for the educational conferences that includes graduates and include a mechanism to support and provide Continuing Medical Education for graduates by providing access to updates of educational materials.

Arkansas

D58HP05181
Daniel Knight, MD
University of Arkansas for Medical Sciences
Department of Family and Preventive Medicine
4301 W. Markham St., Slot 530
Little Rock, AR 72205-7199
Tel: 501-686-8820
Email: KnightDanielA@uams.edu

The goal of this project is to improve resident education in clinical preventive services in an underserved family medicine population.  Prevention is an integral part of primary health care.  Our prevention education curriculum has emphasized the cognitive domain rather than attainment of observable skills and specific prevention-related competencies.  As such, we have been unable to meet national and local goals of providing clinical preventive services.  We propose to improve residency training in prevention by revitalizing our entire preventive services curriculum with various educational strategies and experiences to improve residents' performance.  To determine the effect of our initiatives, we will set specific targets to which we will contrast our results. 

Our educational strategies will stress specific clinical topics that will provide a framework that can be applied by the resident to most areas of their current and future patient care.  First, we will review the prevention curriculum and assess clinical areas for barriers to preventive care.  Based on this appraisal, we will reorganize the curriculum and teach the residents to document family history and evaluate the patient's familial risks and to use this information as an opportunity for counseling about lifestyle changes.  Residents will develop proficiency in screening for routine disease risks, lifestyle issues and genetic risks. Educational methods that will be used include Chart Stimulated Recall and a Quality Improvement project.  A portfolio will be developed by each resident that demonstrates their understanding of how, when and why to use certain screening assessments.  In addition, the residents will be taught to use a software program within the EMR to complete a family history to measure and stratify patient risk.  Residents will learn to navigate the healthcare system, including preventive billing and coding, and will be taught methods of advocating for change in the health system.  Behavioral change for tobacco abuse and obesity will be model areas to teach residents to decrease risk in a patient population.

Project Objectives:

1. Improve resident skills in risk assessment for routine screening, lifestyle health risks, and genetic risks;
2. Teach residents behavioral change strategies within the context of smoking and obesity using motivational interviewing techniques; and
3. Teach the principles of communication of genetic risk to residents.

California

D58HP05136
Patrick Dowling, MD, MPH
University of California, Los Angeles
David Geffen School of Medicine at UCLA
Department of Family Medicine, Room 50-078
Los Angeles, CA 90095-1683
Tel: 310-825-8234
Email: pdowling@mednet.ucla.edu

Under new leadership that began 6 years ago, the 25 year old Division of Family Medicine was elevated to departmental status.  Many important changes have occurred in these 6 years that address the Healthy People 2010 national initiative's two major goals: (1) to increase the quality and years of a healthy life and (2) to eliminate our country's health disparities.  We have combined two UCLA Family Medicine residency programs located just 3 miles apart into one large one with 36 residents using a community hospital, Santa Monica UCLA, and university hospital and a county hospital.  We propose to teach our residents how to manage chronic disease using a group model as an innovative approach to the epidemic of chronic disease - diabetes, obesity and asthma.

In doing so we thought we could best prepare our residents to care for all segments of the populations here as the 10 million folks who live in Los Angeles County not only include some of the richest in the world but also the poorest as the U.S. Census has documented. Further, Los Angeles County now has the largest poverty population in the nation coupled with a record 2.2 million people who lack public or private insurance.

The rationale for addressing the 3 chronic conditions of diabetes, obesity and asthma is that they represent overwhelming epidemics in the population we serve, especially our low income Hispanic and African American population. If Family Medicine is to survive, we need to one patient in one exam room at a time.

The methodology here, simply stated, is to adopt and modify the "Chronic Care Model" endorsed by the AAFP and developed primarily by Edward Wagner, MD., Group Health in Seattle, Washington and written about by Kevin Grumbach and others of UCSF Family Medicine.  We propose to restructure the "resident in clinic" month that occurs in each year of the residency, to include participation in an ongoing series of groups of patients with either diabetes, asthma or obesity. The goal is to provide the resident with an example on how they might adapt such a group model to their next 35-40 years of practice by demonstrating the role of both physician and non-physicians as well as patient self care in the group process.  An asthma project linked with obesity will also occur at the Sun Valley Middle School, a Los Angeles public school with 3,000 year-round students of whom 96% are Hispanic.

Project Objective:

Develop a new model of care for the next generation of family physicians to address chronic diseases.

D58HP05131
Edward Epstein, MD
University of California, San Diego School of Medicine
Department of Pediatrics
9350 Campus Point Drive, Mail Code 0971
La Jolla, CA 92037-0971
Tel: 858-657-8335
Email: ejepstei@ucsd.edu

Pediatric residency programs at the University of California, San Diego (UCSD) and the Naval Medical Center, San Diego (NMCSD) are rich with primary care, cross-cultural training experiences in medically underserved communities.  We aim to maintain or enhance the experiences that make our graduates culturally sensitive to numerous ethnic peoples in San Diego.  There are 42 pediatric residents at UCSD and 17 pediatric residents at NMCSD.  These two primary care training programs collaborate on a number of joint training experiences, including a combined Community Pediatric rotation.  Each provides one-month long primary care block rotations in each of the 3 years of training, weekly continuity clinic experiences, and a rotation in Adolescent Medicine and Development Behavior.  Detection and management of domestic violence is taught in an additional two-week rotation at UCSD.  Training in cultural competency of pediatric residents occurs throughout the 3-year program, with emphasis coming during the Community Pediatrics rotation.  The curriculum focuses on medically underserved areas of San Diego: the inner-city (known locally as "Mid-City"), Indian reservations, the Mexican border, and neighborhoods with immigrants from Asia and Africa within which there are multiple cultures.  The proposed program will maintain these cultural strengths and emphasize management of oral health and mental health problems.  Training will occur within the existing block rotations and during ongoing didactic seminars.

We will teach management and referral of aberrant childhood behaviors, school-related learning and attention problems, and maternal post-partum depression.  The proposed program will provide our graduates with enhanced knowledge about and improved skills to manage oral and mental health issues.  Collaborative models of care that involve other professionals will be learned.  Our program will also give residents the quality improvement (QI) proficiency needed to apply new practice management skills in any clinical environment.  Residents will learn to self-monitor practice behaviors and to understand how operational systems of a clinic or medical office can work to inhibit or enhance the quality of the care which they provide.  Each resident will complete at least one QI project, preferably in the field of either mental or oral health.  All of the above will be achieved by augmenting the teaching forums that already exist within the residency program.  These are: seven one-month long block rotations in primary care, adolescent medicine, community pediatrics and development/behavior.

During the primary care block and Adolescent Medicine rotations, residents will learn a specific collaborative care model that has been shown to be very effective in the education of trainees.  They will work side by side with mental health “interns” from a neighboring university’s mental health professional training program.

D58HP05139
Henderson, Mark, MD
University of California at Davis
Division of General Internal Medicine
4150 V Street, PSSB Suite 3100
Sacramento, CA 95817
Tel: 916-734-2812
Email: Mark.Henderson@UCDMC.UCDavis.edu

The University of California at Davis Health System (UCDHS), in partnership with the County of Sacramento Department of Health and Human Services (DHHS), proposes to implement and evaluate an innovative pilot model of General Internal Medicine (GIM) education to serve the medically underserved of Sacramento County: the Transforming Education and Community Health (TEACH) program.  As the safety net hospital for our region, the UCDHS turns no one away from the hospital, but these patients have extreme difficulty obtaining outpatient follow-up, due in part to severe primary care physician shortages.

The rationale for this program is based on several local and national trends that threaten medical care and education: (1) as a designated primary care health professions shortage area, Sacramento County needs to train, recruit and retain more GIM clinicians; (2) nationally, medical students and residents continue to turn away from primary care careers suggesting that IM training programs must be redesigned to rekindle interest in GIM; (3) the Hispanic/Latino population, the most rapidly growing minority, underutilizes medical and mental health services and carries a high burden of co-morbid mental and medical disease. As the most ethnically diverse county in the U.S., Sacramento County provides a unique setting to enhance training in culturally competent care and to address health disparities.  This grant will support a novel model of GIM education focused on improving access to high quality care, and integrated mental health and diabetes care with a special emphasis on the local Hispanic/Latino population.

Project Objectives:

The long term goal of the TEACH program is to improve access to high quality health services by producing GIM physicians who provide well coordinated, evidence-based, culturally competent care to underserved adults with chronic illness. To reach this goal, we have planned activities under the following three objectives:

1. Develop, implement and evaluate an innovative model of GIM education that prepares physicians to meet the challenges of chronic illness in the medically underserved;
2. Demonstrate that the TEACH model's emphasis on continuity of care and interdisciplinary team management reduces health disparities outlined in Healthy People 2010; and
3. Increase the number of primary care physicians involved in clinical care and education with medically underserved communities in California.

D58HP05142
Lyn E. Berry, MD
Alameda County Medical Center
E 31^St Street, QIC 22116
Oakland, CA 94602
Tel: 510-437-4122
Email: lberry@acmedctr.org

Chronic conditions have become the most common problems in health care.  Primary care physicians must have the knowledge and skills to lead the health care reorganization needed to address this trend.  Training residents in the skills necessary to interact with patients in a culturally competent manner and educating them about the impact of health literacy on patient self-management and medication safety is critical.  Approximately half of our patients are African American; 18 % Hispanic; 16% White; 13 % Asian or Pacific Islander and 3 % are from numerous cultures.  Patients speak more than 30 languages.  Our goal is to have our resident and faculty population more closely match that of our patient population.

Project Objectives:

1. Develop a didactic curriculum for quality improvement in chronic disease management that is integrated into the primary care core curriculum;
2. Train residents to care for urban underserved patients with chronic diseases using the principles and tools of the Chronic Care Model and the Model for Improvement. ;
3. Train residents in quality improvement methodology by using clinical guidelines and patient registries to create quality improvement projects;
4. Train residents to work in multidisciplinary teams in hospital, HMO, and community health settings;
5. Increase residents' knowledge and awareness of how the attitudes and values of both the patient and the provider affect clinical interactions;
6. Train residents in empathetic and culturally sensitive interviewing techniques to improve self-management skills of patients from different ethnic and educational backgrounds;
7. Create a didactic curriculum for residents in health literacy;
8. Create and implement a curriculum to develop a culturally appropriate approach to improving medication use with low health-literate and/or limited-English proficiency patients;
9. Train residents to identify patients with low health literacy and to facilitate improved outcomes in behavioral health and medication safety;
10. Train residents in the principles and functions of public health, including community health needs assessment, health promotion, health protection, and preventive interventions;
11. Increase underrepresented residents during first year of funding to 50% and an additional 10% each year, and increase underrepresented faculty by 10% each funded year; and
12. Increase retention of underrepresented residents and faculty by 10% and increase reported satisfaction with residency/faculty experience.

D58HP05132
Alice Kuo, MD, PhD, MEd
David Geffen School of Medicine at UCLA
Department of Pediatrics
1100 Glendon Avenue, Suite 850
Los Angeles, CA 90024
Tel: 310-794-2583
Email: akuo@mednet.ucla.edu

The Medicine-Pediatrics Quality Improvement in Primary Care (MPQIPC) Project will enhance our residency program to train physicians to work with underserved populations and prepare them to provide effective and improved care for patients with chronic illness.  The ultimate aim of this project is to increase the number of physicians from underrepresented minority backgrounds working as medicine-pediatrics physicians and to increase the number of medicine-pediatrics physicians caring for medically underserved populations.

The purpose of our project is to provide a residency program in combined Internal Medicine and Pediatrics that trains physicians to work with underserved patients and prepares them to employ (1) best practices in chronic care and (2) quality improvement methods to improve care for patients with chronic illness.

Reducing racial/ethnic and income disparities in health outcomes, particularly those associated with chronic conditions of diabetes and obesity, requires more effective health care.  National studies and professional recommendations for training show that care must be transformed by preparing a more effective workforce.  Yet the training experiences of physicians fall short.  Increasing the number of primary care physicians who are interested and well-trained to work with low-income ethnic minority groups requires more than the frequent practice of locating residents' continuity clinic in a medically underserved community site.  Primary care physicians need to have the tools to meet the challenges inherent in providing care to populations with high burdens of disease and low levels of resources.  Physicians also need the skills to change the care environment in their clinic or practice using skills of quality improvement.  This project will produce more informed, prepared medicine-pediatrics physicians.

Project Objectives:

1. Produce medicine pediatrics physicians with the knowledge and skills to practice person-centered primary care in medically underserved communities;
2. Produce medicine-pediatrics physicians who will understand the systems level issues in the provision of high quality primary care to people with chronic conditions, especially diabetes and obesity;
3. Provide program trainees with training to prepare them to be leaders in improving the quality of medical care; and
4. Increase the number of program trainees (minority and otherwise) working in primary care and with underserved populations.

D58HP05179
Susan Snyder, MD
Harbor-UCLA Medical Center
1124 W. Carson Street
Torrance, CA 90502
Tel: 310-222-5654
Email: ssnyder@labiomed.org

Nearly 100 million people in this country live with one or more chronic health conditions.  Data from many sources suggests that our current system of health care is poorly designed to meet the needs of this growing population.  As part of Los Angeles County's health care safety net, Harbor-UCLA Family Medicine Residency serves a population that experiences high rates of chronic illness and a disproportionate burden of suffering from such conditions as a result of poverty, racial and ethnic health disparities, and lack of a regular source of care.  Fully dedicated to training physicians to provide primary care to underserved populations, the Harbor-UCLA Family Medicine Residency, has an excellent track record of recruiting residents and faculty from diverse ethnic backgrounds with a strong commitment to providing high quality care for underserved populations. The Harbor-UCLA Family Medicine Residency plans to address the need to improve chronic illness care for this specific patient population by developing an innovative Chronic Care Curriculum.  Resident learning will be evaluated using tools recommended by the ACGME.

Support for this curriculum exists at all levels within the organization, from the LA County Department of Health Services to the Medical Center's director of ambulatory care as well as the director of graduate medical education.  This project will prepare us to have input into a county-wide disease management initiative, to participate in planning and implementing a hospital-wide chronic care model, and to provide a curricular model to other training programs.

Project Objectives:

1. Organize 24 second and third year residents, fellows and faculty into Learning in Action teams that will be the vehicle to implement the Chronic Care Curriculum;
2. Develop a medical knowledge component of the Chronic Care Curriculum using evidence-based guidelines to teach prevention, diagnosis, and management of common chronic conditions;
3. Provide 12 second and third year family medicine residents per year with training in basic health care quality improvement methods using a data-driven approach to improve chronic illness care;
4. Train 36 family medicine residents in skills that foster self-management in patients with chronic illnesses; and
5. Enhance the existing practice management curriculum to include principles and practice of system redesign and health care organization needed to improve chronic care.

D58HP05185
Alice Kuo, MD, PhD, MEd
David Geffen School of Medicine at UCLA
Department of Pediatrics
1100 Glendon Avenue, Suite 850
Los Angeles, CA 90024
Tel: 310-794-2583
Email: akuo@mednetucla.edu

The goal of the Community Health and Advocacy Training (CHAT) Program in Pediatrics is to graduate a new generation of pediatricians who have the capacity to be effective community leaders and change agents through an innovative training program comprised of comprehensive curricular experiences, a community-based continuity clinic, and strong relationships with community agencies.  Our first HRSA grant allowed us to create a comprehensive residency curriculum in community pediatrics and child advocacy, establish an infrastructure with faculty to support the delivery of this curriculum, and implement innovative programs in the community.  The purpose of this proposal is to move into Phase 2 of CHAT, which will strengthen and enhance the training innovations, implement and evaluate community-based programs, train residents and faculty in the use of new technology, enhance training in cultural competence and children's oral health.

The UCLA Community Health and Advocacy Training Program in Pediatrics will train a new generation of pediatricians who have the capacity to address the health and developmental problems facing today's children.  They will specifically provide effective health and health-related services that are essential for achieving Healthy People 2010 objectives.  Exposure to the CHAT curriculum was found to be associated with significantly higher resident skill in new curricular areas including identifying community resources, child advocacy, interacting with child care facilities, working with foster/care adoption issues, provision of care for families in the welfare system, and being more likely to volunteer for community activities as compared to residents in the comparison group.

Project Objectives:

1. Develop and implement a one-week long seminar series for second-year residents in the CHAT program that will address the Priority Focus Areas of child and family development, obesity/nutrition, and asthma;
2. Create expanded and enhanced mentorship in a new "Guild" system for residents in the CHAT program, as well as for residents in the categorical pediatric track who are interested in community health and/or child advocacy;
3. Provide residents with experience in the implementation and evaluation of community-based programs in the three Priority Focus Areas (PFAs): child and family development, obesity/nutrition, and asthma;
4. Train residents in the use of new technology now available;
5. Strengthen / expand the cultural competence training component for CHAT residents; and
6. Develop and implement a children's oral health component for CHAT residents.

D58HP05186
Tyson Ikeda, MD
University of California at San Diego (UCSD)
200 West Arbor Drive Mail Code #8809
San Diego, CA 92103
Tel: 619-543-5776
Email: tikeda@ucsd.edu

The purpose of this proposal is for the UCSD Family Medicine Residency Program (UCSD FMRP) and the Scripps Family Practice Residency Program (Scripps FPRP) to collaboratively expand community-based education and training of family medicine residents by the design and implementation of core curriculum experiences with 3 special populations within the San Diego Border Area: 1) Rural Medicine in California's Imperial Valley and east San Diego county, 2) Adolescent Medicine in a school based health clinic at Southwest High School, and 3) Domestic Violence (DV) education at the Family Justice Center in Downtown San Diego. The project will develop and implement innovative education and evaluation strategies involving: 1) competency Assessment utilizing standardized patients (SPs) and stealth SPs, 2) creation of distance learning infrastructure for educational activities between residency programs and rural sites, and 3) training in the community oriented primary care (COPC) model as a process for assessing the health care needs of rural communities.

The Imperial Valley, Anza Borrego State Park and the Mountain Empire community of Campo offer limited medical services due to geographical isolation and difficulty recruiting physicians. In the Imperial Valley town of El Centro, Latinos make up 72% of the population and 65% of individuals who speak Spanish at home. Southwest High School is located in an impoverished area 6 miles from the US-Mexico Border in the Sweetwater Union School District.  Demographics show that the schools are 80-85% Latino with large proportions of non English or limited English proficiency. A study on domestic violence found that 38% of hospitals work with local community DV programs and only 1/3 of physicians and nurses had any training in DV.  The study recommended the creation of a centralized services and improved health provider competency.  On October 8, 2004, President Bush recognized the San Diego Family Justice Center (FJC) as the model behind the creation of the Presidential FJC Initiative that earmarked $20 million for the creation of 12 more FJCs in the US.

Project Objectives:

1. Design and implement a rural health curriculum for 48 family medicine residents from the UCSD FMRP and Scripps FPRP;
2. Design and implement a curriculum to expand adolescent medicine training for 48 family medicine residents from the UCSD FMRP and Scripps FPRP; and
3. Design and implement a DV curriculum for family medicine residents from the UCSD and Scripps Family Medicine Residency programs.

D58HP05188
Robert Baron, MD, MS
University of California at San Francisco
400 Parnassus Avenue, A-405
San Francisco, CA 94143-0320
Tel: 415-476-0438
Email: baron@medicine.ucsf.edu

This proposal seeks to design and implement an innovative primary care internal medicine curriculum using new teaching and new evaluation methods to optimally train residents to meet the goals of the Title VII program.  This curriculum will emphasize active learning including case-based seminars and a clinical and experiential curriculum and will involve partnership with multiple community-based sites serving the underserved.  Learning will be amplified using a web-based teaching support system.  Measurement of outcomes will be conducted utilizing a web-based evaluation system and will include evaluation of learning, resident behavior, and patient outcomes.

The purpose of our project is to enhance the preparation of graduates of UCSF's Primary Care Internal Medicine Residency Program to care for patients in underserved communities.  In keeping with federal initiatives to decrease health care disparities and assure a competent health care workforce, we will emphasize the knowledge, attitude, and skills needed to provide quality of care to all patients, including vulnerable populations and those with special needs.  We will train residents in underserved settings and we will develop curricular innovations to teach new material in important new subject areas.  We will emphasize cultural competency in all aspects of our project.  We also plan a concerted effort to recruit more disadvantaged students to our residency and will work collaboratively with other UCSF and community-based programs to extend the impact of our efforts.  We will also develop new evaluative techniques to demonstrate the effectiveness of our project.

Project Objectives:

1. Train 72 residents in professionalism, patient safety, quality improvement, health literacy, mental health, oral health, and genetics;
2. Train 72 residents in prevention and health disparities to provide them the knowledge, attitudes and skills needed to achieve the goals of Healthy People 2010;
3. Design and implement a new evaluation strategy utilizing clinical vignettes to assess the preparation of 72 residents for care of the underserved and high risk populations including the elderly, individuals with HIV/AIDS, substance abuse, homeless, victims of domestic violence, mental health disorders, chronic disease, oral health, genetics, and professionalism;
4. Expand collaborations within UCSF to enhance learning in health disparities and primary care throughout the educational continuum; and
5. Recruit more students from disadvantaged backgrounds into our residency by creating an innovative resident-led elective in minority health for junior and senior medical students.

Georgia

D58HP05178
Donald W. Brady, MD
Emory University, School of Medicine
69 Jesse Hill Jr. Drive
Atlanta, GA 30303
Tel: 404-378-3659
E-Mail: dbrady@emory.edu

The General Internal Medicine/Primary Care (GIM/PC) Residency Program, created in 1996, prepares generalist physicians to provide high quality, cost effective health care, while focusing on the underserved patients at Grady Memorial Hospital, our major teaching hospital located in a medically-underserved community (MUC) of inner-city Atlanta. Our program prepares graduates to deliver comprehensive, well-coordinated, longitudinal primary care services responsive to the needs of patients, their families, and the community.  Eighty percent of all our graduates have entered and remained in generalist careers, and 48% of our current residents are from underrepresented minority or educationally disadvantaged groups. The major goals of this application center on new approaches to improve the declining health status of our nation, particularly that of underserved communities, while we continue the outstanding innovations of our past nine years.

The General Internal Medicine/Primary Care (GIM/PC) Residency Program at Emory has a trifold purpose:  1) to continue to produce outstanding general internists with a focus on primary care practice; 2) to recruit disadvantaged and underrepresented minority physicians into general internal medicine; and 3) to train these general internists, in a setting of culturally competent care, about the needs of underserved populations, such as those cared for at Grady Hospital and its affiliated programs.

The past 9 years of HRSA funding have led to many achievements including:  1) 81 trainees into our primary care program; 2) 80% of our graduates in primary care practice; and 3) 48% of our current residents coming from underrepresented minority or disadvantaged backgrounds

Project Objectives:

1. Train residents in the importance of physical activity and exercise;
2. Have residents develop projects to promote increased physical activity among their patients, particularly those from underserved backgrounds;
3. Train residents in the influence of overweight and obesity on health;
4. Train residents in improving diabetes management in underserved populations;
5. Train residents in health literacy-related issues through a Clear Health Communications Program;
6. Train residents in patient safety/process improvement;
7. Expand our professionalism curriculum; and
8. Continue to recruit 40-50% of residents from underrepresented minority backgrounds.

Idaho

D58HP05180
William M. Woodhouse, MD
Idaho State University
309 Fine Arts Building, Box 8046
Pocatello, ID 83209
Tel: 208-282-4508
Email: wdhouse@fmed.isu.edu

The Idaho State University Department of Family Medicine (Department) will use Residency Training in Primary Care funding to create a learning environment that epitomizes quality, safety and patient-centered orientation.  Through this Project the Department will embrace the New Model of Care endorsed by the Future of Family Medicine Project.  With implementation of the New Model of Care barriers to access will be addressed through open access scheduling.  The chronic care model including Teaching Group Visits and Shared Medical Appointments will be adopted.  And practice measurement processes will be developed that promote quality improvement, best practices and patient safety.  The Project will include faculty training, technological innovations, multidisciplinary case conferences, didactics, rotation curricula and a new Transition of Care Program that will be developed to improve patient safety and quality improvement processes.

The Residency provides comprehensive training in a broad range of practice settings with an emphasis on the care of under-served populations in Idaho and the Intermountain West..."  Pocatello Family Medicine (PFM) is the Residency's family practice center where a full spectrum of primary care services is available.  By February of 2005 PFM will complete implementation of a fully functioning electronic health record. 

As a rural, community-based, university-affiliated family practice residency, the Department has a history of seeking out opportunities to care for many underserved and vulnerable populations, including HIV patients, uninsured, MSFW's, Native Americans, Hispanics, incarcerated women and juveniles.  This Project directly addresses quality improvement, patient safety and practice restructuring priorities that are established by the Institute of Medicine, the Future of Family Medicine Project, Healthy People 2010, the Accreditation Council of Graduate Education, the Joint Commission on Accreditation of Healthcare Organizations and the purposes of the grant program.

Project Objectives:

1. ISU Family Practice residency faculty will acquire a high level of expertise and leadership roles in quality improvement and patient safety;
2. Pocatello Family Medicine will implement innovations that characterize the New Model of Care; and
3. Clinical rotation components and didactic curricula will be developed and implemented that train family medicine residents in quality improvement, best practice pathways, patient safety and professionalism.

Indiana

D58HP05134
Paul Daluga, MD
Union Hospital, Inc.
1606 N. 7^th Street
Terre Haute, IN 47804-2706
Tel: 812-238-7479
Email: fppld@uhhg.org

The Family Practice Residency (FPR) program was established by Union Hospital (UH) in 1976.  The program has grown from 4 residents in training to 18 (6 in each class) and graduated 114 physicians, many of whom have established practices locally.  The Family Practice Residency (FPR) program is a part of Union Hospital (UH) in Terre Haute, Indiana, a town of approximately 60,000. UH, established in 1892, is located in west central Indiana and is a 343-bed non-profit regional medical referral center serving over 200,000 patients annually.  With the addition of the RTT in 1992, the MCRH established a federally-designated Rural Health Clinic as an additional training site.  The Clay City Center for Family Medicine Rural Health Clinic and Training Center was established in 1993 in southern Clay County in a federally-designated Medically Underserved Area (MUA).

Multiple methodologies will be utilized for evaluation, including through OSCEs with each OSCE station incorporating at least one type of assessment tool.  Statistical analysis of data collected via our electronic medical records system will also enable us to assess many of the elements included within this proposal.  Also included in the electronic medical records CDM flow sheets will be cells for self-management and Health Related Quality of Life mental health scores.  Use of these elements can be tracked electronically for data analysis, feedback and program improvement.  Pre-and post-test data from the Intercultural Development Inventory (IDI) will be analyzed to assess residents' cultural competency progress and for program improvement.

Each objective within this proposal is designed to incorporate a hands-on, multidisciplinary approach to learning and with a focus on assessment and dissemination regarding what works and what doesn't work toward achieving an overall goal of eliminating disparities in accessing quality health care in rural America.

Project Objectives:

1. Develop and implement a four-module curriculum that provides family practice residents with systematic hands-on practice, through utilization of a Human Patient Simulator (HPS), to develop and refine basic and complex skills in a patient-safe environment through scenarios that include chronic disease management (CDM) and cultural competency considerations;
2. Strengthen and integrate our Cultural Competency curriculum throughout the core curriculum; and
3. Prepare family practice residents to identify, address and develop solutions to socioeconomic and cultural barriers in the successful delivery of CDM.

Kansas

D58HP05176
Alison Dobbie, MD
University of Kansas
School of Medicine
3901 Rainbow Boulevard
Kansas City, KS 66160
Tel: 913-588-1927
Email: adobbie@kurnc.edu

The University of Kansas Medical Center is a tertiary care clinical, educational and research center serving the state of Kansas.  A major part of the institution's mission is to produce primary care physicians to serve rural Kansas.  In our project, we compare and contrast our traditional community oriented primary care (COPC) curriculum with a new community-based training model in a randomized controlled trial.  In our new model, we develop a community medicine curriculum based on a needs assessment of practicing primary care physicians in four settings — inner urban, urban fringe (suburban), rural and academic.  Family medicine residents will form 1-2 year longitudinal partnerships with community physicians to design, implement and evaluate projects that impact the health of the practice community.  We will also measure patient outcomes and the impact on health care access and disparity brought about by residents' projects.  If successful, our model is highly exportable to other primary care residencies, and has the potential to impact access to health care and health disparities at the primary care practice level.

Primary care physicians are ideally placed to improve access to care and reduce health care disparities at their local practice level, but many lack the knowledge and skills to effectively impact community health.  Our new model is designed to increase the relevance of residency community medicine training to real world practice.  Also, the new curriculum will prepare family practice residents to meet the new quality assurance requirement for maintenance of certification.

Project Objectives:

1. Develop a community medicine curriculum based on an educational needs assessment of primary care physicians in four practice settings; rural, inner urban, urban fringe (suburban) and academic (academic department and community residency faculty);
2. Develop and evaluate in a randomized controlled trial a longitudinal model of community medicine training where family medicine residents partner for 1-2 years with a community physician practicing in the resident's chosen future practice setting, e.g. inner urban or rural; and
3. Conduct a practice-based community medicine project that will impact the health of the practice community.

Kentucky

D58HP05189
Timothy Shawn Caudill, MD, MSPH
University of Kentucky, College of Medicine
K514 Kentucky Clinic, UKMC
Lexington, KY 40536
Tel: 859-257-5499
Email: tscaudl@email.uky.edu

The Primary Care Internal Medicine residency training at the University of Kentucky Medical Center has a long-standing record of successfully training primary care internists, and many graduates locate their practices in rural, underserved communities.  This success has been largely due to targeted recruitment of residents to the program who have a high likelihood of meeting the program's goals and integrating community-based training sites in rural communities into the curriculum.  The faculty in the Division of General Internal Medicine at the University of Kentucky have a strong record of success in developing innovative training interventions and evaluation in educational research, especially in program and residency performance evaluation, curriculum development and evaluation, and presenting outcomes at educational conferences and through publications.  The Primary Care Residency Program is a separate training track within the Department of Internal Medicine's core residency program, administrated by faculty in the Division of General Internal Medicine and Geriatrics.

Of the ten HP 2010 Leading Health Indicators identified that will be used to measure the health of the Nation over the next ten years, our state scores poorly in the majority of them, especially in the medically underserved populations.  Kentucky has a high rate of obesity, tobacco use, domestic violence, chronic pain, substance abuse, and poor health literacy skills, especially in rural and poor urban populations.  The rural, Appalachian population is increasingly challenging, with a disproportionately aging population and a high rate of lower socio-economic, under- and uninsured patients, and educationally disadvantaged population.  Finally, many patients living with HIV/AIDS have poor access to specialists in their communities and rely on generalists to provide their primary health and HIV care.  Achieving a balanced work force, especially in the under-represented minority populations, is especially challenging for our program, more critical today with the influx of a large population of migrant Hispanic workers seeking employment on local and rural farms in our state.  These challenges offer ample opportunity for our primary care training program to revise our educational interventions to improve our performance in these areas.

Project Objectives:

1. Improve training in the care of elderly patients;
2. Improve training in the care of HIV/AIDS populations;
3. Improve training in substance abuse and chronic pain patients;
4. Improve training in the care of victims of domestic violence;
5. Provide training in patient safety, medical errors and quality improvement; and
6. Improve the residents' training in health literacy awareness and cultural competency and to improve the diversity of our trainees and faculty.

Maryland

D58HP05135
Patricia Evans, MD
Georgetown University
Providence Hospital Family Practice Residency
4151 Bladensburg Road
Colmar Manor, MD 20722
Tel: 301-699-7707
Email: evansp@georgetown.edu

The overall purpose of this project is to develop service-related learning experiences for residents in collaboration with Congress Heights, a federally-qualified community health center located in the poorest Ward in Washington, D.C.  Ultimately, the outcomes will be to: increase the number of physicians that work in underserved areas, increase the competency of the workforce, and improve the recruitment and retention of minority faculty and residents. Together, the individual components of this program will provide a cohesive and powerful service-learning experience for residents.  This program will provide residents with effective tools for addressing healthcare disparities by providing high quality care for at-risk patients.

Training involved in this proposal will be conducted at our well-established Family Medicine Center at Georgetown University and at Congress Heights Community Health Center (CHCHC), the community partner site located in the poorest ward of Washington, D.C.

The physicians at CHCHC are assigned to Care Management Teams and focus on specific chronic diseases.  The members of the Care Management Team track the clinical outcomes of the care provided using an electronic patient registry system.  CHCHC is trying to improve clinical outcomes for high-risk patients by developing new programs including a geriatric home visit program and accessible nutritional services with an on-site nutritionist.  This proposal incorporates these unique features to create a curriculum to teach residents how to track clinical outcomes to improve care to high-risk minority patient populations.  It will also address the regional need to develop effective nutritional treatment programs as well as programs to slow the increasing incidence of Type 2 diabetes.  Finally, it will focus on needs specific to Ward 8 of Washington, D.C., including the need to increase services to geriatric patients and the need for programs to address the increasing incidence of childhood obesity.

Project Objectives:

1. Develop a quality improvement curriculum focused on clinical outcomes to teach an evidenced based approach to reducing health care disparities;
2. Increase systems-based practice skills in the area of healthcare for the underserved;
3. Improve interpersonal and communication skills by learning how to work with a health care team to address the nutritional needs of at-risk patient groups; and
4. Improve professionalism by improving cultural competency.

D58HP05145
Kari Alperovitz-Bichell, MD, MPH
University of Maryland
Department of Family Medicine
29 S. Paca Street
Baltimore, MD 21210
Tel: 410-328-2550
Email: kbichell@som.umaryland.edu

To achieve Healthy People 2010 goals the primary care physician workforce requires training in new systems of care to be able to address health disparities.  Our goal in this residency-training project is to teach our residents the most effective ways to achieve positive chronic disease outcomes during day-to-day urban primary care practice.  We plan to accomplish this by instituting the Chronic Care Model (CCM), a system for reorganizing medical practices, in order to promote evidence-based, population-oriented, and patient-centered care for chronic conditions.  Diabetes will be the first chronic disease for which we implement the CCM, with additional chronic diseases (depression, pediatric asthma) added when systems are well established.  These new curricular elements will emphasize evidence-based therapy, self-management support, quality improvement methods, and patient-centered communication topics including cultural competence and health literacy.  This project will be facilitated by close collaboration with the University of Maryland's Joslin Diabetes Center.

The CCM identifies 6 essential elements of the health care system that are required to achieve high quality chronic disease care.  These elements are 1) Health System Re-organization, 2) Self-Management Support, 3) Decision Support, 4) Delivery System Design, 5) Clinical Information Systems, and 6) Community Resources. Our practice will make changes in each of these areas as we implement the CCM.  Of the numerous changes that we will make, some of the most important are briefly outlined here.  Each change will have 2 or 3 of the following functions: 1) improving systems of care for our patients, 2) improving resident learning opportunities, and 3) facilitating evaluation of new program processes, resident learning, and clinical outcomes.

Project Objectives:

1. Develop and implement a high quality ambulatory training experience at UFM by implementing the Chronic Care Model, beginning with the management of diabetes, and adding depression and pediatric asthma in subsequent years;
2. Develop and implement a required Chronic Care Improvement block rotation that will provide experiential learning in: 1) diabetes related medical knowledge, 2) team care of diabetes, 3) quality improvement, 4) accessing community resources for chronic disease self-management support, 5) brief behavior change counseling techniques (motivational interviewing), 6) smoking cessation support, and 7) patient centered communication, incorporating cultural competence and health literacy issues; and
3. Develop and implement a longitudinal didactic curriculum on the above seven themes, to be integrated into our current structure of conferences, reinforced by PDA summaries, and disseminated via Internet technology.

North Carolina

D58HP05137
Clark Denniston, MD
University of North Carolina at Chapel Hill
Department of Family Medicine
CB #7595
Chapel Hill, NC 27599-7595
Tel: 919-966-3711
Email: clark_denniston@med.unc.edu

The Aycock Family Medicine Building, housing the UNC Family Practice Center is the site for the didactic, administrative and continuity practice portions of this project.  The FPC offers full-scope family practice services to 14,000 patients making over 40,000 visits per year.  Inpatient care is offered on the Family Practice Hospitalist Service at UNC Hospitals.  The Family Practice Maternal and Child Health Service (MCH) provides labor and delivery services for women receiving prenatal care at the FPC and for women who receive prenatal care at health department and UNC-affiliated practice sites.

This curriculum will include new rotations in all three years of residency and active learning experiences in existing rotations in the FPC, FP Hospitalist Service and FP MCH Service.  These capstone experiences will help residents synthesize core principles in an increasingly sophisticated way over their three years of training.  We have also begun to adjust our regular conference curriculum, substituting clinical team meetings for one Critical Appraisal Rounds per month.  We will offer 3 new rotations, 1 in each year, which will synthesize and reinforce the broad applicability of principles encountered throughout the three-year curriculum.  Topics for our other conferences will be adjusted to include new presentations that address core principles of QI & Patient Safety to include curricula related to:

1. Team-based continuity practice
2. Hospitalist-based inpatient medicine
3. Comprehensive maternal-child health care that spans outpatient and inpatient settings
4. Practice-based improvement in access and patient satisfaction
5. Chronic disease care outcomes improvement
6. Systems-based identification and reduction of errors

Project Objective:

The objective of this project is to develop, implement, evaluate and disseminate a comprehensive redesign of our residency curriculum based on principles of Quality Improve­ment and Patient Safety.  We will accomplish this objective by using new rotations and existing components of the curriculum to teach the application of QI and Patient Safety principles.  We will target 3 settings across the continuum of care: team-based continuity practice, hospitalist­-based inpatient medicine, and comprehensive maternal-child health care that spans outpatient and inpatient settings.

New Hampshire

D58HP05184
Gail Sawyer, MD
New Hampshire Dartmouth
Family Practice Residency
250 Pleasant Street
Concord, NH 03301
Tel: 603-227-7000 x4790
Email: nhdfpr@cncc.org

The New Hampshire Dartmouth Family Practice Residency Program (NHDFPR) is sponsored by Concord Hospital and closely affiliated with the Department of Community and Family Medicine (DCFM) at Dartmouth Medical School 50 miles away.  Concord Hospital is a 240-bed community hospital with a strong mix of tertiary, secondary, and primary care services.  This has created a solid financial base that allows a strong commitment to community needs.  The family practice residency was started ten years ago with a focus on care of the underserved and on practice innovations.  The facility for our project is the residency training practice, the Capital Region Family Health Center and our Hillsborough satellite.  Our faculty includes 12 family doctors, 2 obstetricians, 3 pediatricians, 1 geriatrician, 4 mental health faculty, plus nurses, social workers, and community partners who will be actively involved in this project.

The specific goal of this proposal is to create an integrated curriculum and 6 month experiential learning module to teach "Personal Medical Home" care to our residents.  This model of care can be taught by focusing on effective access for 5 vulnerable populations, continuity within relationships, interdisciplinary teamwork, and continual improvement of practice, all delivered within the context of patient/family centered care.

To meet our objectives we will first develop three curricula: one for the core concepts underlying medical home care, one for the specific medical knowledge needed for each target population, and one for a longitudinal learning experience aimed at integrating knowledge into practice. Second, we will create a longitudinal learning experience by integrating our PGY3 pediatrics, geriatrics, family health center, and community oriented primary care (COPC) into a 6 month Medical Home block.  Third, we will implement Medical Home teaching activities, assessment and feedback, and specific learning goals throughout our Residency program. Fourth, the creation of an the internet infrastructure to become an ongoing educational resource for the development of the medical home model for our own graduates, community practitioners, and other Family Practice training programs is planned.

Project Objectives:

1. Develop an integrated medical home curriculum;
2. Create the practice changes necessary for a longitudinal learning experience;
3. Teach medical home care; and
4. Disseminate and evaluate our learning from the project.

New Jersey

D58HP05187
Susan G. Mautone, MD
University of Medicine and Dentistry of New Jersey (UMDNJ)
New Jersey Medical School
Pediatric Residency Program
185 South Orange Avenue
Newark, NJ 07101-1709
Tel: 973-972-7160
Email: mautonsu@umdnj.edu

This application proposes to enhance primary care training for the largest pediatric residency program in the State of New Jersey with new and innovative program elements that reflect our commitment to improving pediatric training to better address health disparities and health literacy, improve patient safety and healthcare quality, promote workforce diversity and increase the likelihood of trainees remaining in underserved areas.  The vast majority of patients served by our facilities are underrepresented minorities, with African-Americans comprising 53% and Hispanics 30% of the population. Of this population, 20% are homeless and live in temporary shelters.

This project will assure that our graduates have the requisite competencies to provide culturally aware, safe, high-quality care, education and advocacy for our underserved populations well into the 21st century.  It will assure a healthcare workforce competent in diagnosing, evaluating and managing infants, children and adolescents with asthma, hypertension, the metabolic syndrome and mental health disorders.  Residents will develop skills in educating and partnering with patients and families to effect enhanced health literacy, behavioral change and primary prevention of the complications of these disorders.  While we have succeeded in achieving a more diverse, culturally sensitive workforce, with underrepresented minorities constituting 52% of our recent graduates, there is a pressing need to continue to expand on our current grant-supported efforts to implement a learner-centered academic support program for underrepresented minority and disadvantaged trainees.

Project Objectives:

1. Design, implement and evaluate curriculum elements for pediatric trainees to address health disparities and promote health literacy for these HP 2010 targeted areas: pediatric asthma, obesity, hypertension, diabetes and the metabolic syndrome and child and adolescent mental health, school performance and mental health disorders;
2. Develop enhanced competencies in medical record documentation, medication ordering and quality assessment to ensure resident competence in ongoing evaluation and improvement of their patient care activities and to enhance health care quality and patient safety; and
3. Continue ongoing efforts to promote diversity in the pediatric workforce by developing and implementing enhancements to a learner-centered program of individualized academic support for our underrepresented minority trainees.

New York

D58HP05141
Carmen M. Dominguez-Rafer, MD
New York-Presbyterian Hospital
Columbia University Medical Center
64 Nagle Avenue
New York, NY 10040
Tel: 212-544-1880
Email: cad9005@nyp.org

The overall goal of our project is to improve residents' ability to provide culturally competent care in an urban, underserved community.  We will accomplish this goal by 1) implementing a multi-disciplinary Integrative Care Conference curriculum that will provide intensive cultural-sensitivity training; 2) enhancing our existing geriatrics curriculum by incorporating the Columbia Cooperative Aging Program's innovative Clinical Reasoning module; and 3) enhancing the cultural competency training of our home visits program by introducing a Narrative Ethics component.

The program is needed at the Center for Family Medicine for the following reasons:

• There is a clear need for highly trained family medicine physicians.
• There is a clear need for highly trained family medicine physicians to serve the underserved.
• There is a clear need for the further development of culturally competent family medicine physicians providing care to the underserved.
• There is a clear need for physicians trained to care for the growing population of elderly individuals in the United States in a culturally competent manner.

The overall goal of this proposal is to expand upon the successful foundation of our innovative programming in cultural competence and narrative competence of future family physicians providing medical care in underserved communities. We are proposing to significantly enhance our innovative, theoretically grounded curricula teaching residents to integrate narrative into everyday practice.  In addition, we hope to more widely disseminate our curricular components, making them available for use in residency and medical education.  Our objectives directly address the Bureau of Health Professions, HRSA, national workforce goal of improving access to a diverse and culturally competent health professions workforce.

Project Objectives:

1. Implement a multi-disciplinary Integrative Care Conference Curriculum that will provide intensive cultural-sensitivity training;
2. Enhance our existing geriatrics curriculum by incorporating the Columbia Cooperative Aging Program's innovative Clinical Reasoning module; and
3. Enhance the cultural competency training of our home visits program by introducing a Narrative Ethics component.

D58HP05173
Mary Duggan, MD
Montefiore Medical Center
3544 Jerome Avenue
Bronx, NY 10467
Tel: 718-920-5521
Email: mduggan@montefiore.org

The Residency Program in Social Medicine (RPSM) at Montefiore Medical Center (MMC) has a 35 year history of training residents in community health centers and community-based practices to prepare them for service to culturally diverse, inner city/urban communities and populations with special primary care needs. We propose to redesign our curriculum, incorporating major Healthy People 2010 elements, as the basis for evaluation of our graduates' achievement of several Accreditation Council on Graduate Medical Education (ACGME) mandated competencies. The project has two goals, both of which require family medicine residents to demonstrate competence in the attitudes, knowledge and skills that they will need now, and in the future, to provide high quality care that contributes to improvement in Healthy People 2010 indicators. Specifically we are targeting smoking cessation and behaviors to improve health outcomes in people with diabetes. These goals will be accomplished through curriculum redesign and faculty development in quality improvement and assessment of effectiveness of a motivational interviewing approach to promote behavior change.

RPSM's family medicine program has an established track record of recruiting and retaining trainees and faculty from underrepresented racial and ethnic groups. It is nationally and internationally known for its innovative and successful curriculum that highlights community-oriented, family systems focus, culturally competent, health promotion/disease prevention perspectives.

To keep the curriculum updated and responsive to recent ACGME mandates and Healthy People 2010 public health priorities require evolution of educational programming.  It is critical that future practitioners of family medicine be fully aware of key health and public health issues and are appropriately prepared to work with their patients to address these issues and modify potentially harmful behaviors.

Project Objectives:

1. Family medicine residents will demonstrate competence in Practice-based Learning and Improvement and Systems-based Practice to reduce health disparities.
2. Family medicine residents will demonstrate competence in Communication and Interpersonal skills particularly in counseling for behavior change and use of a Motivational Interviewing approach.

D58HP05183
Ronald Bainbridge, MD
Bronx-Lebanon Hospital Center
1276 Fulton Avenue
Bronx, NY 10456-3402
Tel: 718-518-5760
Email: rbainbri@bronxleg.org

Bronx-Lebanon Hospital Center, affiliated with the Albert Einstein College of Medicine in New York City, is a safety net provider of health care in the South/Central Bronx, one of the poorest and most medically underserved areas in the nation.

Bronx-Lebanon Hospital Center is the largest provider of health care to hundreds of thousands of people who live in the South and Central Bronx neighborhoods of Tremont-Crotona, Hunts Point-Morrisania, and Highbridge-Mott Haven, medically underserved neighborhoods with predominantly minority residents, health disparities, and high levels of poverty and unemployment. In 2003, Bronx-Lebanon Medical Center provided more than 840,000 emergency and ambulatory visits, enabling it to retain the distinction as one of the largest voluntary hospital emergency services and outpatient providers in New York State.  It also provided 170,000 inpatient days of service and 26,906 inpatient discharges.

The Pediatrics Residency Curriculum Committee at Bronx-Lebanon has examined the training needs of its pediatric residents and, as part of this process, surveyed residents and attendings about curriculum development needs.  The survey identified both cultural competence and evidence-based medicine as high priority areas for further development.

The proposed curricula will be based on adult learning theory and practice, and will emphasize self-directed and experiential learning.  As part of the cultural competence training, residents will role-play doctor/patient interactions with actors; this will be videotaped for analysis and discussion. Likewise, as part of the evidence-based medicine curriculum, residents will be required to undertake a medical research project and to incorporate EBM into everyday practice.

Project Objectives:

1. Create a three year cultural competence curriculum for pediatric residents working in underserved urban community;
2. Improve PGY-1, PGY-2 and PGY-3 pediatric residents' knowledge, attitudes and skills in cultural competence;
3. Create a three year EBM curriculum for pediatric residents working in an underserved urban community; and
4. Improve PGY-1, PGY-2 and PGY-3 pediatric residents' knowledge, attitudes and skills pediatric residents in EBM.

D58HP05190
Andrea Manyon, MD
State University of NY at Buffalo
Department of Family Medicine
462 Grider Street
Buffalo, NY 14215
Tel: 716-898-5972
Email: manyon@buffalo.edu

The overall purpose of this proposal is to prepare  practitioners to care for geriatric patients, to enhance minority recruitment and retention projects_., and to apply teaching innovations in areas of ACGME core competencies - especially professionalism, patient safety, quality improvement, and cultural competency.  Health disparities are more pronounced in seniors because of innate differences that have been compounded over time by variations in life experiences and prolonged environmental exposures.  We will address these challenges by focusing on two goals: 1) Install a Model Geriatric Curriculum to Achieve ACGME Core Competencies, and 2) Increase Minority Workforce Recruitment & Retention.

The first goal will weave a model geriatric curriculum into the existing program so as to fulfill a cross-section of ACGME competency requirements in areas of patient care, medical knowledge, practice-based learning, communication skills, professionalism, and system-based practice.  The second goal will increase the diversity of faculty (educators and investigators) and residents by expanding strategic plans designed to achieve long-term progress toward this objective.  The resident and faculty recruitment plan will be tied to a strategy of linking prospective candidates to. internal mentors and establishing national recognition of the health disparities research programs of the Family Medicine Research Institute by employing an "affinity recruitment" approach.

Given the fact that caring for older people will be a core part of all medical practice for the vast majority of future physicians, the goal cannot be to create more specialists, but rather to ensure that all future primary care physicians are able to meet the needs of their older patients.  Teaching materials in geriatric education, such as the Geriatric Interdisciplinary Team Training materials funded by the Hartford Foundation and the Medical College of Wisconsin's Virtual Patient Teaching Resources funded by the Reynolds & Hartford Foundations, allows us to incorporate recent advances in teaching and understanding of geriatric medicine to create a model geriatric curriculum for family medicine residency training. The proposed curriculum, based on the American Geriatrics Society curriculum guidelines, will fulfill a cross-section of ACGME competency requirements to achieve knowledge and skills required for quality geriatric care.

Project Objectives:

1. Enhance competency in Comprehensive Geriatric Assessments;
2. Enhance competency in the Management of Geriatric Syndromes;
3. Enhance competency in facilitating System-wide Medical Decision Making; and
4. Increase Minority Workforce Recruitment & Retention.

Ohio

D58HP00368 - Supplemental
Joseph Kiesler, MD
University of Cincinnati
Eden & Sabin Way
Cincinnati, OH 45267-0582
Tel: 513-721-2221
Email: kieslehj@fammed.uc.edu

The University of Cincinnati Department of Family Medicine has a HRSA-funded Residency "Underserved Track" parent grant for two second-year and two third-year residents.  The goal of this grant is to supplement our parent grant by providing training in public health policy and advocacy at the local, regional and national levels, with a focus on mental health public policy.

Our Parent Grant Goal is to prepare family practice residents training in a Federally Qualified Center to recognize and address the unique healthcare needs of minority and other underserved patients, function as their advocates, and serve as local public healthcare leaders.  Our Supplemental Grant Goal is to provide training in public health policy and advocacy at the local, regional and national levels, with a focus on mental health public policy.

The national need for primary care training in the care of underserved populations is compelling. The health professions workforce needs clinician leaders who grasp public health policy issues relevant to the indigent and underserved.  Our curriculum will teach resident Family Physicians ways to identify and reduce disparities and barriers to mental health care.  Our last ACGME review noted a deficiency in our Community Health curriculum, stating "it is limited to a few lectures with no participatory activities for the residents".  The parent grant addresses this by involving residents in local advocacy projects.  The proposed supplemental project addresses the deficiency by providing training in public health policy at the federal as well as the local and regional levels.  National public health policy related to mental health will be highlighted in the curriculum.

Each resident will complete a mental health policy project over the course of the year.  The general topic will be the problem of the fractured public health care system for low-income patients with co-occurring physical and behavioral health conditions.  The aim of the project will be to instruct and experientially inform residents on the processes involved in policy research and advocacy.

Project Objectives:

1. Develop faculty knowledge and skills in public health policy so they may create and sustain a public health policy curriculum for resident physicians training in an underserved track of a residency program; and
2. Teach residents about public health policy and its development, giving them the knowledge and skills they will need to serve as leaders and advocates for underserved populations.

Oklahoma

D58HP05177
Kathryn E. Reilly, MD
University of Oklahoma
Department of Family and Preventive Medicine
900 NE 10^th St.
Oklahoma City, OK 73104
Tel: 405-271-2569
Email: kathy-reilly@ouhsc.edu

This three-year initiative, which we are calling the Chronic Goal-Directed Care (CoGDoC) Project, will include the development, implementation, and evaluation of a curriculum designed to teach family medicine residents in the three residency programs (OKC, Enid, Lawton) administered by the Department of Family and Preventive Medicine (DFPM) at the University of Oklahoma, to use the Chronic Care (CCM) and Goal-Directed Health Care (GDHC) Models to improve the care provided to patients with chronic illnesses and increase the delivery of preventive services.  The curriculum will build knowledge, skills, and attitudes relevant to the following competencies defined by the Accreditation Council for Graduate Medical Education (ACGME): systems-based practice, practice-based learning and improvement, interpersonal communication skills, and patient care.  Faculty and staff will also be trained to teach, model, and reinforce CC and GDHC principles.

Oklahomans die from chronic illnesses at a rate substantially higher than the national average, and while the death rate in the country as a whole has decreased in the last five years, the death rate in Oklahoma has increased.  The prevalence of diabetes mellitus among Native Americans, who constitute 7.9% of the state's population, has increased by 50%.  Oklahoma also lags behind the rest of nation in the delivery/receipt of most preventive services.  Our hope is that this project will improve the health of Oklahomans.

The CoGDoC Project will require the addition of a new curriculum as well as reorganization and reorientation of the existing curricula to allow for its implementation. Committees will be formed to plan, develop, and implement each component of the project.  The Curriculum Committee with representatives from all three programs will develop a common set of curricular goals, objectives and methods of evaluation.  Each program will then develop specific instructional strategies for achieving project goals and for implementation of the new curricular components.  A faculty development program with common and program-specific features will also be developed to prepare faculty to implement the curricular changes in their own practices as well as part of their clinic precepting activities.  A training program will also be developed to prepare staff for the changes anticipated in the clinics.  Evaluation will be conducted continually and formally reviewed annually.  These results will be used to improve the curricula.

Projective Objectives:

1. Develop, implement, and evaluate the new residency curricular elements;
2. Develop, implement, and evaluate faculty and staff development programs; and
3. Evaluate the fidelity (implementation) and efficacy (outcomes) of the overall project.

Oregon

D58HP05140
Robert G. Ross, MD, MScEd
Cascades East Family Practice Residency
Oregon Health and Sciences University
Merle West Medical Center
2801 Daggett
Klamath Falls OR 97601
Tel: 541-885-4612
Email: robr1228@aol.com

We are administered by Oregon Health and Sciences University, which is the only medical school in the State, and by virtue of our affiliation have access to all of the facilities associated with a large university medical school.  Residents experience extensive training in frontier and rural partner sites.

This continuation proposal includes the addition of training and a curriculum in the care of patients with chronic pain, development of advanced obstetrical skills for resident trainees, expansion of a unique PDA based patient information system into the outpatient setting in the family medicine center, the provision of a mobile, electronically advanced outreach clinic for the homeless, and funding for enhancement and further dissemination of a published, proven Evidence Based Medicine curriculum.

Project Objectives:

1. Increase exposure of residents to diverse populations in community settings providing care to special populations to include other groups of patients, including those in 2. below, chronic pain patients, high-risk OB patients, and the homeless;
2. Enhance development of the curriculum for residents and faculty in the care of special populations, including patients with chronic pain, high risk OB patients, and the homeless, in addition to those included in the previously awarded supplemental grant: 1) end of life care/hospice 2) psychiatric care in rural settings 3) chronic disease delivery predicated on a multi-disciplinary model 4) integration of a sports medicine curriculum, and 5) use of distance education for sharing of educational resources;
3. Expand the development of an objective-based curriculum and evaluation system for the trainees in new aspects of the project that will be exportable to other programs (EG chronic pain), and test the effectiveness of this model in the delivery of care to this population;
4. Establish a model handheld based wireless information system to use in the outpatient setting that will improve efficiency and safety of patient care, and will be transferable to other programs/settings and implement a curriculum in patient safety for resident physicians;
5. Demonstrate the use of a fully equipped mobile clinic in care delivery to a vulnerable population;
6. Update and disseminate a proven methodology to teach residents the principles and practice of EBM; and
7. Disseminate results of this project to other educators through presentation and publication.

Pennsylvania

D58HP05138
Patrick McManus, MD
Thomas Jefferson University
Department of Family Medicine
1015 Walnut Street, #401
Philadelphia, PA 19107
Tel: 215-955-0643
Email: patrick.mcmanus@jefferson.edu

The overall goal of this project is to improve the education and diversity of family medicine residents in order to better address the population health and mental health needs of underserved patients, and to train a more diverse physician workforce.

This training will take place at Jefferson's Family Practice Center as well as at more than 10 community based sites caring for the underserved.  Residents will be trained in: principles and strategies of population health, health literacy, patient safety, protection against environmental hazards, promotion of healthy behaviors, and accessibility of health services.  Each resident will be provided with 48 new hours of lectures and workshops during their 3 years of training. Residents will participate in a longitudinal experiential curriculum, consisting of 20 half-day sessions.  These will include on-site exposure to the work of public health agencies, hands-on use of population health databases, participation in and exposure to federal and city-wide projects in chronic disease management, work in community based health literacy and health education programs, and population health / primary care partnership projects.

We plan to train residents to meet the mental health needs of vulnerable populations, including homeless women & children, individuals with substance abuse problems, the LGBT (lesbian, gay, bisexual, and transgender)population, people with HIV/AIDS, and the elderly.  We plan to develop didactic as well as experiential components, using our extensive community based training facilities in underserved communities, and new primary care / population health partnerships.  In order to increase the number of URM residents in our program, we plan to develop an enhanced recruitment and retention program.  This will include new program features such as: an URM advisor system and mentorship track, an URM resident serving as liaison to Jefferson's Office of Diversity and Minority Affairs, development of a Hispanic health interest group, development of minority health electives, a medical Spanish course, and recruiting URM minorities for the combined family medicine residency / MSPH program.

Project Objectives:

1. Develop and implement a new required curriculum on "Meeting the population health needs of underserved communities", and to develop and implement a new combined family medicine residency / Masters of Science in Public Health (MSPH) track;
2. Develop and implement a new required curriculum on "Meeting the mental health needs of underserved populations"; and
3. Develop and implement an enhanced_, program for recruitment and retention of URMs in family medicine.

D58HP05175
Richard Neill, MD
University of Pennsylvania
Family Practice Residency Program
51 N. 39^th Street, Mutch Building 6^th Floor
Philadelphia, PA 19104
Tel: 215-662-8949
Email: rneill@mail.med.upenn.edu

We propose to develop and implement a multidisciplinary home visit program that will bridge current gaps in our curriculum between hospital, office and home.  In so doing we hope to strengthen our practice management, community medicine and inpatient curricula by educating residents to integrate home care into their continuity practice.

The University of Pennsylvania family practice residency is a 6-6-6 residency that graduated its first resident class in June of 2001.  Our curriculum emphasizes community medicine through longitudinal and block rotations throughout the residency.  As a result our residents work closely with the surrounding community, a predominantly African-American neighborhood with poor health indicators common to urban settings.  Needs assessments of our patients and of their surroundings have pointed out many health indicators that are sensitive to home care interventions, including a rising incidence of asthma hospitalizations, poor prenatal and perinatal outcomes, and disparities in access to care among others.  Although many home based services have emerged to meet these needs and other more traditional long term care needs, physicians rarely perform home visits, and residency training to the new responsibilities inherent in utilizing home services is lacking.

We propose creation of a home visit curriculum that recognizes the new responsibilities physicians have for delivery and coordination of home care services.  We intend to create a dedicated curriculum that integrates physician home visits into residents' continuity practice in a way that emphasizes culturally sensitive collaborative care as a means of leveraging already existing home care resources in our community.

The project includes a six-month period of program development followed by implementation of longitudinal and block experiences in a fashion that integrates home visits into the residents' continuity practice and block rotations.  Residents will perform home visits with a multidisciplinary home visit team that will educate residents via hands-on experience with attention to the specific knowledge and skills necessary for performing these visits independently in the urban setting.

Tennessee

D58HP05133
Roger Zoorob, MD
Meharry Medical College
1005 Dr. D.B. Todd Blvd.
Nashville, TN 37208
Tel: 615-327-6438
Email: rzoorob@mmc.edu

The project proposes to make significant and long term changes in the aim, structure, and operations of the Family Medicine residency program at MMC in order to better prepare residents for practice in medically underserved communities in Tennessee and the nation.  The residency program proposes to transfer two training sites to community health centers, expand the use of an electronic medical record (EMR) to the two new sites, and revise the community medicine curriculum to incorporate a community oriented primary care (COPC) approach for training family physician residents for practice in medically underserved communities.  This community health center training approach is consistent both with President Bush's Health Information Technology initiative that sets a broad goal that most Americans should have electronic medical records within 10 years and with the position of the Future of Family Medicine report which has taken a formal position that 50% of family medicine residency training programs should be using EMRs by the end of 2005.

Methodology will include 1) establishing the process for shifting the training of the 12 (4-4-4) remaining residents from the Meharry FMC (located on the campus of Meharry Medical College/Metro General Hospital) to two federally qualified health centers: Cayce CHC and Matthew Walker CHC; 2) modifying the community medicine curriculum to include both a longitudinal component and a community-based research block rotation inclusive of didactic presentations and practice management, health promotion and health policy practicum experiences, and structured learning activities that occur across all three years of training and 3) expanding the use of the Practice Partner EMR from the Madison FMC to Cayce FHC and Matthew Walker CHC, over the three years of the project, so that all family medicine residents receive the same experience in utilizing health information technology to carry out clinical, health promotion, practice management, and professional and scholarly activities.

Project Objectives:

1. Twelve Family Medicine residents will be transferred to urban community health centers located in medically underserved areas for their continuity experience by the end of year three;
2. Eighteen Family Medicine Residents will complete a revised and expanded community medicine curriculum by the end of year three; and
3. Eighteen Family Medicine residents per year will utilize an electronic medical record (EMR) to conduct clinical care, practice management, health promotion, and community based research at Madison FMC, Cayce FHC, and Matthew Walker CHC by the end of year three.

Texas

D58HP05120
Virginia Niebuhr, PhD
University of Texas Medical Branch at Galveston
Department of Pediatrics
301 University Blvd.
Galveston, TX 77555-1119
Tel: 409-772-2357
Email: vniebuhr@utmb.edu

The mission of the University of Texas Medical Branch (UTMB) is “Were for the Health of Texas” conveying the philosophy that UTMB stands committed to providing scholarly teaching, innovative scientific investigation, and state-of-the-art patient care in a learning environment to directly better the people of Texas.  In alignment with this mission, UTMB has a long history of serving indigent and low-income populations.  Within the Department of Pediatrics, we know that our patient populations are a valuable resource, providing residents and students learning opportunities with children and families from diverse ethnic, cultural and socio-economic groups.

The Pediatric Residency Program at the University of Texas Medical Branch proposes the C5 Project, highlighting five needs we have identified to help us better prepare residents to enter primary care practice and to care for medically underserved and at-risk children in Texas. We address an overriding need for development of a culture of objectives-based and competency-based education among faculty and residents, and we address specific needs for Curriculum Mapping, enhanced Competency Assessment, a new Curriculum for Nutrition & Obesity Prevention, and enhanced Career Entry Support. 

The C5 Project will impact 53 residents per year: 36 Categorical Pediatrics, 15 Combined Medicine-Pediatrics, and 2 Combined Pediatrics-Dermatology.

Project Objectives:

1. Curriculum e-Mapping Initiative (a curriculum management objective): development and implementation of a web-based curriculum e-map to help us evaluate and manage our residency curriculum;
2. Competency Evaluation Initiative: (an evaluation objective) development and implementation of enhanced competency-based evaluation strategies;
3. Nutrition and Obesity Prevention Curriculum (a curriculum development objective): development and implementation of a longitudinal and integrated obesity prevention curriculum; and
4. Career Entry Initiative (a career development objective): providing career development assistance to our residents to help them identify and secure primary care practice opportunities in rural and underserved areas.

D58HP05146
Carlos A. Dumas, MD
University of Texas Health Science Center at Houston
P.O. Box 20036, JJL308
Houston, TX 77225
Tel: 713-500-7610
Email: Carlos.A.Dumasa@uth.tmc.edu

Located in the Texas Medical Center in Houston Texas, The University of Texas Health Science Center is a state-funded University.  We are affiliated with the Harris County Hospital District and other not-for-profit hospitals including the Memorial Hermann Hospital system.

A major mission of the Family Medicine Residency Program at the University of Texas Medical School at Houston is to train primary care physicians to serve the indigent and culturally diverse population in Houston, Texas.  Two of our clinics are in underserved areas of Houston, and our third clinic has many uninsured patients or patients with only Medicare or Medicaid coverage.  In the main, our patients suffer from chronic illness -- usually more than one.  Dedicated to serving these patients caught in the nexus of poor health, poor conditions of living, and isolation from familiar culture, our residents need training beyond the routine level.  They need skills sufficiently varied and complex to match the needs of our underserved patient population.  Because many non-medical dimensions of life affect the patients' ability or even desire to follow medical advice, we want to train our residents to investigate and respond to those dimensions with as much sophistication as they do the medical dimensions.  An estimated 20,000 patients in 3 urban clinics in the Houston area will be served or affected by the proposed program.  Since chronic illness is a leading cause of disability and death all over the United States, particularly among minorities, a model for training residents to a level of excellence in caring for patients with such illness will benefit all programs charged with preparing physicians for this great task.

We will place psychology interns in our clinics and teach residents how to collaborate with them in caring for patients with chronic illness.  In two seminars, they will learn factors that signal the need for collaboration and guidelines for making it most useful.

Project Objectives:

1. By the end of 3 years, we will have trained 60 residents to use an index, the SF-36, to assess and document the health related quality of life for patients with chronic illness.
2. By the end of 3 years, we will have trained 60 residents to use motivational interviewing and brief interventions to improve the progress of patients with chronic illness who score low on the SF-36 — the index assessing health related quality of life.
3. By the end of 3 years, we will have trained 60 residents to apply, as appropriate, 3 advanced interventions for patients who show insufficient improvement with motivational interviewing and brief interventions.
4. By the end of 3 years, we will have trained 60 residents to support their professional development in treating patients with chronic illness with practice-based evidence.

D58HP03350 - Supplemental
Miguel Angel Ramirez-Colon, MD, MPH
University of Texas Health Science Center at San Antonio
Department of Family and Community Medicine
Mail Code 7795, 7703 Floyd Curl Drive
San Antonio, TX 78229-3900
Tel: 210-358-3931
Email: ramirezma@uthscsa.edu

Building on the cultural competency training and mental health skills introduced in the original grant, we propose to integrate these focus areas into our Family-Centered Maternity Care curriculum.  The comprehensive curriculum will include evidence-based instruction about core maternity care topics, targeted cultural competency training related to the care of women and families during pregnancy, childbirth, and the postpartum period, and specific mental health promotion activities appropriate for the perinatal period.  Twenty-six percent of pregnant women suffer from depression during pregnancy, and 10-15% are diagnosed with major depression during the first postpartum year.  By focusing on mental health promotion, we will improve the pregnancy outcomes and overall health of the women and families in poor and underserved communities.

Improve access to comprehensive Family-Centered Maternity Care (FCMC) for poor/underserved women and their families by training family medicine residents to provide pregnancy, childbirth, and postpartum care that integrates Evidence-Based Medicine, Cultural Competency, and Mental Health Promotion.

We will augment our maternity care curriculum with cultural competency training and mental health promotion, thereby integrating the skills introduced in the original grant into a focused clinical area.  We will reinforce these skills during residents' perinatal care using three key activities: 1) Shadowing, 2) Ethnography and 3) Physician Precepting.  Faculty joining the project will participate in the training developed for the overall project.  The new ethnographic skills for maternity care will be presented for participants throughout the project.

Outcome evaluation will involve assessing residents' knowledge/attitudes about maternity care, practice preferences, and successful acquisition of skills.  Process evaluation will involve documenting successful completion of the ethnographic skills workshops, FCMC workshops, shadowing sessions and birth stories review sessions.

Project Objectives:

1. Evidence-Based Medicine
2. Cultural Competence
3. Mental Health Promotion

West Virginia

D58HP05144
James G. Arbogast, MD
West Virginia University
Department of Family Medicine
P.O. Box 6845
Morgantown, WV 26506
Tel: 304-293-1533
Email: arbogastj@rcbhsc.wvu.edu

The mission of the West Virginia University (WVU) Robert C. Byrd Health Sciences Center is to improve the health of West Virginians through the education of health professionals, basic/clinical research, continuing professional education, and by providing health care services.  There is considerable synergy between the grant objectives since both are targeting skills in the resident physician that will contribute to lessening the disparities of access to and quality of care by improving community health and psychological services, increasing sensitivity to literacy as a barrier to health care, and improving communication/interviewing skills in the low literacy population.  This will be accomplished by focusing on two educational levels - clinical and curricula. One, we will develop a multi-disciplinary teaching clinic within the arena of a free health clinic to serve the homeless within our community.  And two, we will develop new curriculum, a Health Literacy OSCE, a Guest Lecture series, and hands-on workshops to improve provider communication skills to reach patients with limited literacy and cultural uniqueness.

The Department of Family Medicine at WVU is a well established university program founded in 1973.  Since its inception, the Department has been actively committed to providing primary health care services and the recruitment, training and retention of primary care physicians in largely rural West Virginia.  The WVU Family Medicine Residency program is the oldest in the State.  To date the residency program has graduated 128 family physicians, 91 of which initiated practice within the state, and 98% are still in primary care.  The Morgantown residency is a 6-6-6 program with 18 residents currently enrolled in the program. This proposed project will impact at least 74 residents (54 FM and 20 other specialties) during the 3-year time frame.

Our patient care base (42,000 visits a year) is 62% female and 38% male; 62% private insured, 16% Medicare; 16% Medicare; and 6% uninsured; 85% from West Virginia with 15% from Maryland and Pennsylvania; the racial mix is equal to the state's mix with over 95% being white, but higher than the national rate below poverty level.  Though the clinic is not located in an MUC, our service area includes 8 counties listed as wholly in medically underserved communities.

Project Objectives:

1. Crafting a Service-Learning & Clinical Learning Synergy: A Multidisciplinary Homeless Learning Center; and
2. Develop a competency-based curriculum for communication skills with a focus on effective skills for patients with low literacy.

D58HP05182
Konrad C. Nau, MD
WVU Research Corporation on behalf of WVU
886 Chestnut Ridge Road / PO Box 6845
Morgantown, WV 26506
Tel: 304-535-6343 x233
Email: nauk@rcbhsc.wvu.edu

The WVU Rural Family Medicine Residency Program has a mission to prepare residents for successful and effective rural and small community practice.  The purpose of this grant proposal is to develop new curriculum in oral health for underserved populations; develop training to improve patient safety in clinic and hospital settings; and develop a new Hispanic outreach clinic where training in cultural competency will occur.

The WVU Rural Family Practice Residency at Harpers Ferry is a relatively new program developed by West Virginia University and accredited on June 1, 1995.  The residency was designed to be much more community centered than other more traditional residency training programs in the state with the goal of placing graduating residents in underserved and rural communities typical of much of West Virginia.  Over 50% of all off-site training for this program occurs in medically underserved areas and all of the continuity care of the program occurs at the Harpers Ferry Family Medicine Center, a federally qualified Rural Health Clinic.  Recruitment focuses on residents likely to practice in rural and underserved areas, and over 50% of the first 6 graduating classes have chosen to practice in Medically Underserved Communities.

Dental carries remain the single most prevalent chronic disease of childhood. Although dental care has improved over the past 25 years, populations served by rural physicians are experiencing a disproportionate shift of pediatric dental carries with 80% of the caries found in only 25% of children.  Early childhood caries can be prevented and diagnosed by primary care physicians during the first three years of life when most children see their physician regularly, but their dentist rarely, if ever.  In order to impact this problem, rural family physicians will need to augment their fund of knowledge about oral health and understand community systems that directly impact on oral health.

Project Objectives:

1. Primary Care Curriculum in Oral Health - will empower the graduate family physician with the knowledge, skills and attitudes to identify at risk children seen during routine well child checks for an early intervention program in oral health.
2. Cultural Competency and Hispanic Outreach Clinics - will create a new Hispanic outreach clinic to address emerging unmet health care needs and provide training for residents in cultural competency and basic medical Spanish.
3. Curriculum in Patient Safety for Rural Hospitals and Clinics - will create a curriculum and culture of patient safety that imparts in residents the ability to apply a practice-based and systems-based approach to medical error and near miss-clinical events.