1. Developing a Community-Based Family Medicine Clerkship at Wuhan University Medical School in China Family Medicine Global Health Workshop Mari E. Egan, MD, MHPE, Sarah-Anne Schumann, MD and Nicole Baltrushes October 14 2011

2. Learning Objectives Participants will be able to: Describe one US medical school’s experience in adapting their community-based family medicine clerkship for use at a Chinese medical school Describe one US medical school’s experience in adapting their community-based family medicine clerkship for use at a Chinese medical school Identify challenges to implementing community-based family medicine education in a medical school with no family medicine-trained faculty and community sites with preceptors who have minimal teaching experience Apply an approach to international medical education consultations Apply an approach to international medical education consultations

3. Presentation Outline Introduction to the Medical Education system and status of Family Medicine education in China today Introduction to the Medical Education system and status of Family Medicine education in China today Background of the Wuhan University Medical Education Reform (WUMER) project with the University of Chicago Background of the Wuhan University Medical Education Reform (WUMER) project with the University of Chicago Descriptions of clerkship pilot and pilot evaluation findings in Wuhan, 2010-2011 Descriptions of clerkship pilot and pilot evaluation findings in Wuhan, 2010-2011 Review of our consultation on improving and expanding the pilot family medicine clerkship Review of our consultation on improving and expanding the pilot family medicine clerkship

5. Health Care Reform in Modern China 1 Three phases in Health Care Reform since 1949 4 : Three phases in Health Care Reform since 1949 4 : –1. Equal Access to Care during Planned Economy- support for basic level hospitals and primary care –2. Market Oriented System- central government withdraws support for basic services, rise of lucrative specialty care and training in China –3. Balance of equality and efficiency in wake of SARS outbreak of 2003. Emphasis on need for primary care and preventative medicine.

6. Medical Education in China Different University Training Tracks Basic Medicine (7 or 8 years)-goal is to produce students with skills to conduct research and pursue further doctoral training Basic Medicine (7 or 8 years)-goal is to produce students with skills to conduct research and pursue further doctoral training Clinical Medicine (7 to 8 years)-acquire clinical skills to practice as specialist in medicine Clinical Medicine (7 to 8 years)-acquire clinical skills to practice as specialist in medicine Preventative/Clinical Medicine (5 years)-this is aimed at equipping the graduate with basic knowledge to practice community/rural medicine. Most 5yr students @ WU plan to specialize. Preventative/Clinical Medicine (5 years)-this is aimed at equipping the graduate with basic knowledge to practice community/rural medicine. Most 5yr students @ WU plan to specialize.

7. Need for Family Medicine 2 China’s Ministry of Health has proclaimed community based family medicine as a way to contain costs while providing health care for its 1.2 billion people.

8. Wuhan University Medical Education Reform (WUMER) Partnership between WU and U of Chicago Pritzker School of Medicine Partnership between WU and U of Chicago Pritzker School of Medicine Curriculum Reform Curriculum Reform –Basic Sciences –Clerkships  Increase clinical experience  Maintain students initial interest in primary care Funding Funding Role of Family Medicine in WUMER Role of Family Medicine in WUMER

9. Clerkship Training Sites: Community Health Centers More than 100 CHCs in Wuhan, 50-80K people served/clinic More than 100 CHCs in Wuhan, 50-80K people served/clinic Strong community Presence Strong community Presence Inexpensive, transparent pricing Inexpensive, transparent pricing Doctor/Nurse team/ Public Health Worker teams assigned to neighborhoods within CHC service area. Doctor/Nurse team/ Public Health Worker teams assigned to neighborhoods within CHC service area. Home visits Home visits Many are already training sites for nursing and GP retraining Many are already training sites for nursing and GP retraining Programs Programs Services:inpatient services, IV infusion, emergency care, Traditional Chinese Medicine, public health and chronic disease management. Services:inpatient services, IV infusion, emergency care, Traditional Chinese Medicine, public health and chronic disease management.

10. Lessons Learned from Pre-Pilot Visits CHCs are ideal place in Wuhan to learn community and Family Medicine CHCs are ideal place in Wuhan to learn community and Family Medicine CHC physicians are excited to teach CHC physicians are excited to teach –80% said they are ready to teach –100% believed CHC had the capacity for students CHC physicians want more faculty development CHC physicians want more faculty development –Only 50% reported having any special training in community medicine –Majority reported not feeling they had enough teaching experience

11. WU reaches out to Pritzker WU faculty visit Chicago Prtizker Faculty visit Wuhan Pritzker Faculty consult on FM Clerkship curriculum Pritzker Faculty visit to Observe Pilot MS4 visits to evaluate Pilot Pritzker Faculty visit for Teaching Symposium Clerkship Pilot with 8th yrs Clerkship Pilot with 5th yrs Pritzker faculty visit Required Clerkship Launch 2011 2010 2008 2012 2009 Post- Pilot Clerkship TIMELINE 2013 2010 AAFP Global Health Workshop 2011 AAFP Global Health Workshop

12. Family Medicine Clerkship Pilot Autumn 2010 5th year students in 5 year program 5th year students in 5 year program 4 weeks, in Qing Shan Community Health Center 4 weeks, in Qing Shan Community Health Center Co-taught by WU faculty and CHC doctors Co-taught by WU faculty and CHC doctors Weekly Home visits Weekly Home visits Community Health Research project Community Health Research project Small Group Discussions Small Group Discussions Morning clinic time with CHC doctors Morning clinic time with CHC doctors –Focus by week on general practice, Inpatient Ward, TCM, Public Health

13. Reflections on the Clerkship Pilot

14. Clerkship Pilot Evaluation Methods Methods –Interviews  Students, Preceptors, and Clerkship Director –Surveys  Students and Preceptors

15. Clerkship Pilot Evaluation: What Went Well? Feedback from the students: Feedback from the students: –Traditional Chinese Medicine exposure –Small Group Case Discussions –Research Projects –Exposure to Community Medicine –Home Visits –Good Doctor Patient Relationship –Gained Communication skills with Patients

16. Traditional Chinese Medicine Traditional Chinese Medicine –Preceptors consult with TCM doctors weekly –Preceptor estimate that 11-25% of their patients see a TCM doctor as well –Preceptors and students agree that knowledge of and experience with TCM is important for practicing in the CHC Clerkship Pilot Evaluation: What Went Well?

17. Clerkship Pilot Evaluation: What can be improved? Feedback from Students: Feedback from Students: –Students presented 0-3 cases during the clerkship –Students were equivocal about whether this was a sufficient amount –Students enjoyed the feedback they received on case presentations –4wks is too long, students got bored –Often felt unhelpful in clinic –Wanted more intentional teaching

18. Clerkship Pilot Evaluation: What can be improved? Feedback from Preceptors and Directors Feedback from Preceptors and Directors –Great to have students in clinic to increase awareness of Community Medicine and learn communication skills –CHC Preceptors want more Faculty Development to improve their teaching skills

19. Clerkship Pilot Evaluation Conclusions Conclusions –Great success in many areas  Exposure to TCM  Doctor Patient Relationship  Relaying conception of Community Medicine –Faculty Development, of preceptors and WU faculty, needed to address student and preceptor concerns related to passive learning environment

20. Teaching Symposium and Consulting Visit Autumn 2011 Day 1: Teaching Symposium for 62 CHC preceptors from 27 clinics Day 1: Teaching Symposium for 62 CHC preceptors from 27 clinics Lectures: Dr. Egan- “Family Medicine in the US” Dr. Benson- “Teaching in an outpatient setting” Nicole Baltrushes- “Clerkship Pilot Evaluation” Dr. Zhu- “Small Group Discussion” Dr. Dong- “Wuhan University Pilot Clerkship” WU Student- “ Student Perspective on Pilot Clerkship”

21. Teaching Symposium and Consulting Visit Autumn 2011 Day 2-3 Day 2-3 –Visit 4 prospective CHC Clerkship training sites –Talk with CHC staff at each site about outpatient teaching- their capacity and concerns

22. Suggestions and Recommendations 建议 Increase didactic teaching on Family Medicine at the CHCs Increase didactic teaching on Family Medicine at the CHCs Increase hands on patient care with CHC physician preceptors and continual faculty development efforts Increase hands on patient care with CHC physician preceptors and continual faculty development efforts Assign students to one MD/RN/Public health team and be involved in community medicine outreach to that community station Assign students to one MD/RN/Public health team and be involved in community medicine outreach to that community station Possibly reduce passive learning experiences (i.e. shadowing during immunization clinic) Possibly reduce passive learning experiences (i.e. shadowing during immunization clinic) Maintain 4-week clerkship Maintain 4-week clerkship

23. Challenges to Implementing Family Medicine Clerkship in China Lack of Clarity on goals of Clerkship Lack of Clarity on goals of Clerkship Lack of belief in importance of outpatient training Lack of belief in importance of outpatient training Lack of communication between CHCs and WU faculty Lack of communication between CHCs and WU faculty Pritzker Faculty Development- perhaps not completely audience appropriate? Pritzker Faculty Development- perhaps not completely audience appropriate?

24. Next Steps and Ongoing Questions Dr. Egan & Schumann will return Spring 2012 Dr. Egan & Schumann will return Spring 2012 Continued meeting and consulting with WU Clerkship Directors, CHC doctors and students Continued meeting and consulting with WU Clerkship Directors, CHC doctors and students How to do we make our input most effective & prioritize recommendations? How to do we make our input most effective & prioritize recommendations? How do we effectively collaborate with other Universities in China and in the US to make sure we aren’t duplicating efforts? How do we effectively collaborate with other Universities in China and in the US to make sure we aren’t duplicating efforts? How do we encourage grassroots development of the clerkship? How do we encourage grassroots development of the clerkship? How do we inspire the true leaders of Family Medicine to step forward? How do we inspire the true leaders of Family Medicine to step forward? How do Community Doctors gain importance and respect in the medical field? How do Community Doctors gain importance and respect in the medical field?

25. Thank You! 谢谢 Mari Egan MD, MHPE megan@bsd.uchicago.edu Sarah-Anne Schumann MD Sarah-anne-schumann@ouhsc.edu Nicole Baltrushes nbaltrushes@uchicago.edu

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