Mission and Commitment to Primary Care:
“The University of Kansas School of Medicine commits to enhance the quality of life and serve our community through the discovery of knowledge, the education of health professionals and by improving the health of the public.”
As the only medical school in the state of Kansas, a key part of this mission is training developing physicians to meet the health needs of the state. Only five of Kansas’ 105 counties are classified as “urban”; 38 counties are “rural” with between six and 19.9 persons per square mile, and 31 counties are classified as “frontier”, with fewer than six persons per square mile. In addition, many population pockets of the urban counties, especially Wyandotte County (Kansas City), where the medical school is located, are severely underserved. Meeting these needs requires a commitment to primary care and the production of primary care physicians, and KUSOM is a national leader in this arena. Indeed, in the most recent publication on entry of medical students into family medicine, the American Academy of Family Physicians (AAFP) reports that KUSOM is #1 in the country in number (39), percentage (22.4%), and 3-year rolling percentage (21.1%) of students entering family medicine.1
Rationale for Primary Care Research: The majority of funded research studies influencing medicine and health care come from highly specialized researchers in research settings such as tertiary/quaternary care hospital campuses. Clinical research continues to undervalue the benefit of service-learning and participatory methods as a means to advancing our understanding of health disparities in primary care and community settings. There is a pressing need to expand the body of clinical research occurring in primary care settings and use community participatory research methodologies. Primary Care-Based Research Networks44 and collaborative service-learning projects can provide important infrastructure and stability as long-term project funding and sustainability concerns move through inevitable cycles. IAIHD will capitalize on recent advances in health care informatics to bring useful clinical services, novel research questions, and appropriate expertise and energy to collaborative partnerships between researchers, trainees, and community members interested in reducing health disparities. Using faculty development, a strategic mission to assure rigorous evaluation/research, and a theory driven approach to community-based participatory research45 with community member ownership, IAIHD will bring the local and regional community one step closer to the understanding and elimination of health disparities, a target national concern of Healthy People 2010.
National Need: A large body of work supports the contention that research in primary care settings is needed to improve health care and the health of the public.46, 47 As the population ages, information from primary care will become crucial. Since the majority of chronic disease care in the United States is delivered by primary care providers, these providers can significantly influence overall health.48, 49 For minority and underserved populations, this is especially true. Health care workforce analyses have shown that the removal of family physicians from urban and rural geographic areas would lead to a remarkable increase in the total number of physician shortage areas across the U.S.50, 51 Further research within the practices and communities these physicians serve will provide the knowledge to improve health and eliminate disparities for a great number of marginalized patients. This proposal seeks to directly address this need by conducting research with community partners and through rural and urban Primary Care practices serving minority and underserved patients. We will do this using a unique combination of service-learning and information technology approaches.
Local Need: The State of Kansas has experienced significant demographic and economic change over the last several decades.52, 53 After half a century of stability based on agriculture and rural habitation, there has been a dramatic migration of younger individuals to the urban areas of Wichita, Topeka, and Kansas City. In part, as a response to this, there has been an influx of immigrants and 1st generation Kansans to frontier and densely settled rural counties to work for rural industry such as in the meat packing plants of southwestern Kansas. The urban cores of Kansas City, Kansas and Wichita have experienced decay and flight of resources to wealthier suburbs.54 These changes have produced health and access to health care consequences seen by primary care providers and University of Kansas medical students and residents as they work throughout the State.55 There are a growing number of both urban and rural areas with medically underserved and socially impoverished populations. The gap between those with resources and those unable to afford access to health care has widened. The groups most affected by these marginalizing conditions are ethnically, racial and socioeconomically diverse, in spite of the overall homogeneity of the majority population of Kansas when compared to other states. They come from diverse ethnic backgrounds (e.g. Southeast Asians and HispanicsLatinos in southwest Kansas, or African American and Hispanics/Latinos in Wichita and Kansas City), as well as diverse occupational (agricultural or industrial) and residential environs (farm or high rise housing development).52 Counties such as Wyandotte County, the urban core of Kansas City, Kansas, fall amongst the lowest counties in the state by traditional health indicators. Extensive work, including a recent HRSA HCAP grant to the county, has been unable to make significant headway in reversing these disparities. Direct service provision, such as that provided by the JayDoc Clinic continues to be in high demand for those unable to afford routine medical care.
The University of Kansas Medical Center is the medical and health care training facility for the greater Kansas City metropolitan area and for the state of Kansas. It serves as the premier clinical and biomedical research organization within the region with over 65.2 million dollars in current extramural research funding for FY 2005 ($44.6M NIH awards dollars FY05). The School of Medicine has approximately 450 faculty members at its Kansas City campus and 113 on the Wichita campus, and offers masters and doctoral degree programs, as well as statewide continuing education. There are approximately 750 students enrolled in the M.D. program and 150 students in other graduate studies.
Through its clinical, community service, and educational activity the Department of Family Medicine has developed close working relationships with other departments in the School of Medicine, the School of Nursing and Allied Health, the Center on Aging, the office of external Affairs, and the Kansas Masonic Cancer Research Institute. A core faculty of 15 physicians, a clinical psychologist, a medical social worker, two doctoral-level educators, and three nurse practitioners have been successful in all aspects of the educational, service, and research missions of the department. The pre-doctoral program has incorporated family medicine principles and educators in all years of the medical school curriculum, and recent KUSOM calculations found that Family Medicine faculty spend significantly more teaching hours per FTE than any other clinical department within the Medical Center. The residency program is one of the oldest in the United States, with approximately 40 percent of graduates electing to practice the full spectrum of family medicine skills, many in rural communities. A number of other graduates have gone on to work in underserved urban areas and the department continually seeks to meet the workforce needs of the state of Kansas. The department is recognized for its responsiveness to the needs of the community through affiliations with the local county health department, the Wyandotte County Community Health Council, the County Safety-Net Clinic Coalition (WCSNCC), the department supported student-run JayDoc free Clinic, nearby federally qualified community health centers (Swope Wyandotte, Swope Quindaro and Swope Health Central), and a host of community organizations partnering with our community-based residency training initiative.
History of Family Medicine Research at KU Medical Center
Research Programs and Activities: The Department of Family Medicine created a division of research within the department in 2000 to house the 3 junior faculty conducting research with intramural and extramural funds. Although the constitution and composition of faculty in the division has changed – currently one MD and one PhD researcher with 2 affiliated MD research faculty conducting educational research - the Department and the division are committed to building research capacity, working collaboratively with community partners, and achieving significant pre-doctoral, residency, and faculty training objectives along the way.
Research Activities with Medical Students: We have a number of ongoing activities involving students in research. IAIHD will significantly enhance our capacity to train students to participate in service-learning and community research and directly involve them in data collection, patient recruitment, patient tracking, data entry, and results dissemination.
The success of each of our projects in KPEPR has been attributable to student involvement. Since 1999, we have had approximately 25-40 medical students per year (223 total) receive research training and directly assist in data collection, subject recruitment, or direct observation of primary care. Each of these students receives the equivalent of a month long clinical rotation credit for participating in this “Family Medicine 905: Family Practice Research Elective.” Medical student evaluations have been very positive and we routinely have 50 medical students apply for this elective each year. Students are very attracted to the hands-on clinical work they have done with experienced rural preceptors. They find the research activities and training a valuable part of the experience. New incoming classes often learn of the elective through discussions with 2nd, 3rd, and 4th years who have had excellent experiences in the elective.
We have also had great success with the JayDoc Free Clinic, a medical student run clinic which operates two nights a week when all other Kansas City, Kansas safety-net clinics are closed. Drs. Freeman and Greiner, as co-faculty directors assisted students with development and resource procurement for this initiative starting four years ago. The program now involves Board of Directors of 8 students (rotating annually), and 80-90 percent of the entire medical student body assists as clinical volunteers, fundraising, or with committee work in support of the clinic. Board members receive elective credit for service-learning projects and portfolios they complete during each year and the program has received extensive local press and attention recently.
The Community Leadership Track, another elective program, is a selective leadership training program for medical students run by Drs. Greiner and Freeman. Approximately 10 medical students per year apply and are admitted and monthly guest lecture firesides, field trips, or mini-projects make up the core curriculum. Student leaders from the JayDoc Clinic, International Outreach, AMSA, and Rural Medicine Interest Groups make up the majority of the members.
Resident Research Activity: The Residency Program within the Department of Family Medicine has required a hypothesis-based research project for program graduation for over a decade. In the past, these projects were often initiated by residents with advice from assigned faculty mentors. In response to resident suggestions, we launched a new program in 2001 to bring these projects into the research division. Each resident now chooses one of the research division faculty to act as mentor and assist with hypothesis generation, literature searching, project design, human subjects approval, and project implementation. Two hours of dedicated residency curriculum time has been scheduled each week for a small group of 5-6 residents to meet with research faculty to discuss research and to co-learn about primary care research projects. In addition, another group of between 5-6 residents is allotted 2 hours each week to independently work on their projects. Residents are assigned these activities on a rotating schedule so all have sufficient didactic and practical experience over the course of their training. All residents are guided through an institutional online human subjects tutorial which certifies them for work on research projects. We expect IAIHD to draw from our residency pool and assist residents in joining a “project teams” and utilizing the IAIHD process to fulfill their scholarly project graduation requirement. We also expect, based on mentoring 6 cohorts through this process since 2001 that many residents will find IAIHD projects interesting and valuable as they will facilitate community connections and service to the underserved.
Existing Research Activities in Medical Education: KUSOM has been very active in the conduct and publication of educational research. The Educational Research Group, of which the faculty on this grant are members, has been very productive. Drs. Delzell and Chumley, are involved in several recent and current projects, including a project to analyze the skill of providing feedback by different levels of evaluators.5 Delzell studied the subjective comments made to students on summative evaluations and found that the comments made are rarely negative, often very general in nature, and of limited value to students. Dr. Chumley and colleagues developed a workshop to teach students the clinical skill of prioritization. In a comparative trial, they demonstrated that the intervention made no difference in students’ abilities to prioritize information.6 Drs. Chumley and Delzell were funded by a Hewlett-Packard teaching and technology grant to study students’ abilities to find and integrate information during clinical encounters. Their team found that medical students could access information but had difficulty integrating new knowledge into patient care, despite completing structured learning experiences.7 Dr. Chumley and colleagues have been successful teaching clinical skills to beginning third year medical students.8 Dr. Chumley also has experience with evaluation and has published a process of evaluating a web-enhanced curriculum with adapted distance learning benchmarks.9
Drs. Delzell and Chumley have several ongoing educational research projects. They are conducting an evaluation of the types and nature of verbal comments made to students in the ambulatory setting. The next phase of this project is a faculty intervention that will attempt to improve the quality of faculty / student interactions in the teaching setting. They are evaluating patient log data collected by MS3 students on clerkships to determine if a structured mid-clerkship feedback session encourages students to modify their learning experience. They are conducting data analysis from several computer-based clinical cases using artificial neural network technology. The neural network technology is being used to identify the patterns of clinical reasoning used by students. A bibliography of recent educational research publications by our faculty are included in the references2, 5-8, 10-20
Existing Research Activities in Clinical/Community Research: The Department of Family Medicine has a growing and well funded portfolio of community-based research. Departmental faculty have a record of recent health disparities publications.21-26 27-29 The departmentally administered KPEPR network now includes both rural and urban practices with the rural portion just completing a R01 funded smoking cessation project (KanQuit, PI, Edward Ellerbeck, M.D., M.P.H.). Both the urban and rural practices are finishing a NIH funded R21 project (PI, Kim Engelman, Ph.D). In addition, Dr. Greiner’s R01 has begun in 2007 and will run through the urban portions of the network. The urban clinics in the network are primarily safety-net clinics and we have strong collaborative relationships with the Wyandotte County Safety-net Clinic Coalition that oversees joint projects for these 9 clinics. We are currently conducted a large longitudinal project in the County Health Department Clinics (PI, Greiner) and a smoking cessation project (PI, Paula Cupertino, Ph.D.) in several clinics that serve primarily Latinos. A new faculty member, Kim Kimminau, Ph.D., has begun a series of projects with local and regional public health organizations. Since moving to the Department of Family Medicine from her prior post as senior vice president for research and analysis at the Kansas Health Institute seven months ago, Dr. Kimminau has completed an oral health service study and report for the statewide Office of Oral Health at the Kansas Department of Health and Environment. She has begun a Prenatal Care Evaluation Study for the Wyandotte County-Kansas City, KS/Unified Government health department. And she is beginning a large community assessment of a Metropolitan HPV Vaccine Outreach and Dissemination Project. She has established ties to several Medical Center and several external collaborators who will extend the breadth and expertise behind these projects. This range of active projects and development opportunities will provide extensive opportunity for growth of clinical and community researchers.
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The University of Kansas Medical Center