Community Medicine

I. Rationale

As Family Physicians, we must fully understand our patients to most effectively help them optimize their physical, emotional, and social health. We also need to be aware of the forces that impact them. The most easily understood context for our patients is their “family” or household. However, the forces which impact our patients’ health include the physical environment of the home, the workplace or school, the wider health status of the local community, and the resources available to our patients who are not conventionally considered health care environments or services.

This means acquiring knowledge and understanding of the following: workplace (occupational health), school (school health), the home and recreational environments (environmental health) and the socioeconomic environment in which our patients live. (levels of local public and private violence, incidence of teen pregnancy, level of unemployment, transport and shopping infrastructures, and socioeconomic development)

This knowledge of the health problems facing both the local and global community and the resources available within the community (public health) enables the individual practitioner to be more responsive to the needs of their specific patient population and to more effectively improve the health status of their patient population. This is the importance of Community Medicine curriculum.

II. Goals

The goals include to gain the competencies and attitudes listed below specific to Community Medicine and generic to Family Medicine.

A. Perform an evidence-based, evaluation of the community in which the resident practices and its resources.

B. Communicate effectively with a wide range of individuals regarding the community needs and resources.

Attitudes

A. The importance of knowing the community’s needs and resources.

B. The importance of a person’s occupational environment, community schools, recreational environment, and socioeconomic environment as a part of patients' lives.

C. Appropriate evaluation of a community.

D. Awareness of the special needs of communities.

E. Prevention strategies as an important part of the community.

III. Objectives

Medical Knowledge/Patient Care

A. Understand the importance of the workplace in health

1. the economic and psychological consequences of providing a “sick certificate”.

2. the effect of the workplace environment on chronic health problems like asthma, diabetes, obesity, hypertension, and stress/depression, and the effect these conditions have on ability to perform work duties.

3. develop the skills to perform an examination related to an on-the-job injury, and to make appropriate recommendations for return to work.

4. understand the concept of “light duties” and learn how to define these in job-specific ways.

5. develop and demonstrate an understanding of the ergonomics of the work environment and the impact on health and function.

6. develop the skills necessary to advise the patient on prevention of health problems which may occur in association with a specific workplace.

B. Explain how specific aspects of the local community impact on physical, emotional, and economic health.

C. Develop the skills and database to provide the patient with resources available within the community.

D. Understand the role of local government in protecting the health of the community.

E. Become aware of major local employers and specific issues related to those particular industries.

Organization/Business Practice

A. Understand the role of the Family Physician in the community, and the opportunities available to extend the practitioner role into the workplace, the school and the general community.

B. Understand how expanding the role of the physician in the community can lead to improved job satisfaction and a more rewarding practice.

C. Understand the importance of liaison with the local Public Health Department.

D. Understand the roles of the various divisions of the Public Health Department.

Personal/Professional Growth and Development

A. Learn the basic disease concepts involved in occupational-related illness

1. lung disease, including reactions to irritants and immune-mediated reactions

2. skin disease, including primary irritant dermatitis, allergic sensitizers, and photosensitivity

reactions

3. liver disease

4. carcinogens in the workplace

5. CNS-related illness including special sense organs

6. reproductive and genetic concepts

7. trauma, both acute and repetitive

8. stress

B. Improve knowledge of detection, prevention, and management of specific occupationally-related

illness

1. pulmonary disease, including pneumoconioses and asthma

2. occupational dermatoses

3. occupational noise exposure

4. musculoskeletal problems, especially back injuries and repetitive strain injury

5. radiation exposure

6. heavy metal poisoning

7. solvent and noxious gas exposure

8. vibration injuries

9. eye injuries

10. stress in the workplace

C. Be aware of legal issues in the workplace

1. The Americans with Disabilities Act

2. O.S.H.A.

3. Worker’s Compensation Laws

D. Define the demographics of the local community that affect health

1. availability of transport to place of occupation

2. levels of local crime

3. prevalence of HIV, teen pregnancy, hypertension, and diabetes(Type 2), median income,

unemployment level, need for subsidized and public housing

4. availability of drugs of abuse including illegal drugs, and sale of legal drugs(tobacco and

alcohol) to minors

5. identify level of truancy in local schools, drop-out rates and percentage going on to

college

E. Obtain information about health resources in the community which can be of benefit to patients

1. Public Health Department Services

Obtain knowledge of the services available to patients at the local

Public Health Department

a. Travel Clinics

b. Family Planning

c. Communicable Diseases (including HIV and TB)

d. Men’s, Women’s, Teen, Child, and Infant Health Clinics

e. Health Education (car seats, nutrition, WIC)

2. Self -help organizations for physical problems (eg hypertension)

3. Self-help organizations for problems of addiction (eg alcohol,

tobacco, narcotics & food)

F. Understand the services of the Local Health Department to protect the health of the community

1. Environmental Health

food safety/ restaurant inspection

pest control (rodents, insects)

solid waste disposal/ septic tanks

personal care home inspections

swimming pool inspections

2. Epidemiology

tracking reportable diseases

tracking meningitis or hepatitis sources

3. Communicable Diseases

Contact investigation (HIV, TB, GC/Chlam, Syphilis)

TB case managers including directly observed therapy

HIV clinics, and education

Learning Activities
Attending Rounds / Research Conference / X / Outpatient Clinics
Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient care
Grand Rounds / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / Journal Club
Morning Report / X / Faculty Supervision / X / Readings
X / Didactics / X / Procedures
Other
Evaluation Methods
Attending Evaluation / Directly Supervised Procedures / Morning Report
X / Program Director
Review / X / In-Training Exam / X / Faculty Supervision and Feedback
X / 360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other

Interpersonal and Communication Skills

Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients families, community resources, and professional associates. Residents are expected to:

A. Develop patient sensitive skills for interviewing that allow accurate, and complete collection of information regarding symptoms, the family and the community that affect the patient's health and care.

B. Develop skills in communicating results to patients, their families, other health care providers.

C. Develop skills in educating patients and their families, in dealing with sensitive issues for patients and families, and in negotiating a plan of investigation and treatment with the patient and family.

C. Develop professional relationships with co-workers, consultants, ancillary staff and other professionals to enable assembling of health care teams and mobilization of community resources to optimize care of the patient.

D. Use professional language and demeanor when communicating with other residents, with Family Medicine attending physicians, with physicians from other services, with non-physician clinical staff, with non-physician non-clinical staff, and with patients and their families.

F. Create and sustain a therapeutic and ethically sound relationship with patients.

G. Use effective listening skills and elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills.

H. Work effectively with others as a member or leader of a health care team or other professional group.

Professionalism

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:

A. Demonstrate respect, compassion, and integrity; a responsiveness to the needs of patients and society that supersedes self-interest; accountability to patients, society, and the profession; and a commitment to excellence and on-going professional development.

B. Demonstrate a commitment to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices.

C. Demonstrate sensitivity and responsiveness to patients' culture, age, gender, and disabilities.

D. Arrive at the clinic in a timely fashion.

E. Work effectively as a member of a team.

F. Respect patient privacy by guarding medical records and discussion of personal information about patients.

G. Assist patients and their families in planning for future care needs and care decisions based on prognosis for the disease.

H. Support the patient in their healthcare decisions.

I. Demonstrate professional, respectful demeanor when addressing team members, patients, ancillary staff, and consultants.

J. Appear professionally dressed and well groomed.

K. Completes H&P’s, progress notes and discharge summaries in a timely fashion.

L. Attends required daily conferences and grand rounds.

M. Responds to pages in a timely fashion.

Systems-based Practice

Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system & community resources to provide care that is of optimal value. Residents are expected to:

N. Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger community and society and how these elements of the system affect their own practice.

O. Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources.

P. Practice cost-effective health care and community resource allocation that does not compromise quality of care.

Q. Advocate for quality patient care and assist patients in dealing with system complexities.

R. Know how to partner with health care managers, community resources, and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance.

S. Understand the role of the family physician as part of the community.

Learning Activities
Attending Rounds / Research Conference / X / Outpatient Clinics
Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient care
Grand Rounds / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / X / Journal Club
Morning Report / X / Faculty Supervision / X / Readings
X / Didactics / Procedures
Other
Evaluation Methods
Attending Evaluation / Directly Supervised Procedures / Morning Report
X / Program Director
Review / X / In-Training Exam / X / Faculty Supervision and Feedback
X / 360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other

Practice-based Learning and Improvement

Residents must be able to investigate and evaluate their patient care practices, their community, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:

A. Analyze practice experience and perform practice-based improvement activities using a systematic methodology.

B. Locate, appraise, and assimilate evidence from scientific studies related to their patients' and community’s health problems.

C. Obtain and use information about their own population of patients and the larger community population from which their patients are drawn.

D. Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.

E. Use information technology to manage information, access on-line medical information; and support their own education.

F. Learn to incorporate health promotion and disease prevention into patient care.

G. Use evidence-based medicine, evaluation of available evidence, and use of best- available evidence at morning report meetings and during routine clinical care.

Learning Activities
Attending Rounds / Research Conference / X / Outpatient Clinics
Multidisciplinary Rounds / Ethics/Comm Conference / X / Direct Patient care
Grand Rounds / Specialty Conference / Resident Seminar
Sub-Specialty Conference / Noon Conference / Journal Club
Morning Report / X / Faculty Supervision / X / Readings
X / Didactics / Procedures
Other
Evaluation Methods
Attending Evaluation / Directly Supervised Procedures / Morning Report
X / Program Director
Review / X / In-Training Exam / X / Faculty Supervision and Feedback
X / 360 ᵒ evaluation / Videotape Review / X / Quarterly Review
Other

IV. Instructional Strategies (see above)

A. Attend occupational medicine clinics to learn the process of evaluation and follow-up of work-place injuries, and the effect of chronic conditions on the ability to perform job functions

B. Attend Public Health Department clinics to gain an understanding of age/gender/disease/service focused clinics. Work with Public Health Department physicians or staff in four of the clinics or departments described in above. Include one day with Environmental Health, TB Clinic (including directly observed therapy), Communicable Disease working with contact investigators, and one other service such as Travel Clinic, Epidemiology, Family Planning, Cancer screening or HIV depending on availability and individual interests.