The goal of our primary care fellowship program is to provide a strong educational and clinical foundation for primary care physicians who will remain dedicated to the clinical practice and teaching of primary care medicine in medically underserved communities and to conducting research that addresses the primary care research agenda. The major objectives of the fellowship program are as follows.
Improving Fellows' Clinical Skills in General Internal Medicine
Clinical responsibilities are structured to enhance the Fellow's skills in primary care. Special emphasis is given to areas that are relevant to achieving the goals of the Health Objectives for the Year 2020. Specific areas of emphasis include longitudinal relationships with patients and their families, chronic disease management including health promotion and disease prevention, cultural competence, and the medical home model.
Our community is a federally designated Health Professional Shortage Area (HPSA). The patients our faculty, fellows, and residents serve tend to be poor, many are immigrants, many do not speak English, and they tend to experience social and environmental stressors that may amplify their needs or may make their care more challenging.
Under the supervisions of a senior clinician, Fellows work in multidisciplinary teams to provide coverage, back-up, longitudinality, and accountability for defined patient panels. Emphasis is placed on training in primary care, ambulatory medicine, and on teaching the knowledge base, skills, attitudes, and values of community-oriented health care. Division faculty provide supervision and cross coverage on weekends (fellows are not on-call).
Fellows attend the division's weekly clinical conference to discuss important issues faced by general internists. These lectures are presented by Division faculty, fellows and invited guests from within and outside the institution. In addition, fellows also attend the Department of Medicine's weekly Grand Rounds.
Improving Fellows' Teaching Skills
Fellows gain teaching experience and improve their teaching skills in several ways. Fellows precept residents in continuity clinic once a week under the supervision of a senior clinician-educator who provides the fellows with feedback on clinical and educational issues. Each fellow is also responsible for two clinical presentations per year at the Divisions weekly clinical conference. In partnership with a senior member of the Department of Medicine, fellows also spend a month in their second year as teaching attendings in the medical wards. Lastly, fellows may have opportunities to teach in courses in the Schools of Medicine or Public Health.
Completing a Master's Degree
Unlike the ABIM-approved fellowships in the medical subspecialties, there are no formal delineations of training requirements for programs in academic general internal medicine, and no certification process for physicians completing such fellowship programs. Some fellowship programs offer structured course work through affiliated graduate schools (i.e. Schools of Public Health), and a master's degree may be as good or better an alternative to double board certification. In addition, graduate school offers opportunities for interdisciplinary collaborations and new friendships.
In our program, fellows may choose to complete a master's of science (MS) degree in one of several disciplines at Columbia University, specifically: Epidemiology or Health Policy and Management (School of Public Health); Nutrition (Institute of Human Nutrition); Geriatrics (Center for Geriatrics and Gerontology in the School of Public Health); Health Promotion and Disease Prevention (Teachers College). Most fellows in our program have elected to complete degrees in the School of Public Health, in Epidemiology or in Health Policy and Management.
Candidates who accept a position in our fellowship must apply to the Mailman School of Public Health (or other equivalent program) no later than the spring prior to the date of their appointment, especially if interested in the summer courses. Tuition is generally covered by the fellowship program including related expenses such as textbooks.
Improving Fellows' Knowledge of Clinical Epidemiology and Biostatistics
Given their general importance to research and the teaching of evidence-based medicine, the principles of clinical epidemiology are emphasized regardless of the fellows' particular research and degree track. Clinical epidemiology and biostatistics are taught and reinforced in four venues: weekly divisional research conferences, weekly house staff journal club, biweekly fellows meetings (which include general pediatrics and family medicine fellows) and didactic courses for masters' degree programs.
Fellows are expected to take three sequential methods courses in epidemiology, an introductory course in biostatistics and two middle level statistics courses, one on the analysis of categorical data and the other on regression and multivariate modeling. Fellows are also strongly encouraged to take a course on measurement, which covers basic topics such as the reliability and validity of measures, scaling, questionnaire design, factor analysis and data coding. In addition to these methods courses, students may choose from a wide array of substantive epidemiology courses in areas such as infectious disease epidemiology, AIDS, environmental health, cancer, cardiovascular disease, and perinatal epidemiology.
The weekly Division of General Medicine clinical research meetings offer a practical application of these methodologies. These are working meetings based on group process in which fellows and faculty think aloud about current research plans and the group responds with constructive criticism. The methodological discussions of statistical and epidemiologic techniques at these meetings are focused at the level of research implementation, as opposed to the journal club in which the focus is interpretation of research results. The diversity of backgrounds and research interests of this group provides a broad experience for the trainee and tends to pique research interests and foster collaborative efforts between division members. Fellows also serve as junior faculty in the residents weekly Journal Club which has been consistently rated by house staff as one of the most valuable experiences of their training at Presbyterian Hospital. In Journal Club the focus is interpretation of research results and each week fellows take turns leading the discussion in collaboration with a more senior epidemiology trained clinician.
Improving Fellow's Research Skills
Trainees are expected to formulate and conduct at least one and preferably two research projects during fellowship. Few fellows start the program with a mature research project. During the first two months, fellows usually familiarize themselves with the new environment, sit for their Board examination, take up their panel of new patients, and start core courses at the School of Public Health. This format gives new fellows a framework to interact with the faculty and identify a suitable mentor, and to explore research subjects. An essential initial step in the fellows' research endeavor is the selection of an area of interest, both substantive (e.g. cardiovascular disease, diabetes, health access and utilization) and disciplinary (e.g. epidemiology, health policy.)
By the fall of the first year, trainees are expected to identify a research project, submit a written research proposal following the outline of an NIH grant, present their proposal at a divisional research meeting (and possibly also at a biweekly fellows meeting) and - after acceptance of the proposal by the fellowship faculty - begin their project. By the spring of the first year fellows are expected to submit an abstract of their work to the meeting of the Society of General Internal Medicine or the NRSA trainees conference. By fall of the second year, it is expected that a manuscript of the project be completed and submitted to a peer-reviewed journal and work begun on a second fellowship project by winter of the second year.
Commitment to Diversity
Our program is strongly committed to diversity, reflecting the commitment to diversity at every level of the Division of General Medicine. Of all fellows (n=44) since HRSA support for the program began in 1993, 9 (20.5%) are under-represented minorities (AAMC definition), 11 (25%) Asian/South Asian, and 31 (70.5%) women. Among core general medicine clinical ambulatory faculty, 33% (10 of 30) are under-represented minorities, and 53% (16/30) are women.
Reinforcing and Sustaining Fellows' Commitment to Primary Care
Our program is designed to provide successful, enjoyable, and positive experiences in the clinical care, teaching, and research for our fellows. In addition, our program provides broad exposure to faculty who provide positive role models for later primary care career stages and who can and do mentor fellows. We hope that the fellowship will reinforce our fellows' idealism and commitment to primary care, both for those headed for research track careers and those who choose clinician educator track careers. In the last five years (s ince 2006) our program has attracted and trained a group of 14 outstanding fellows. Of these 14, 12 are MDs and 2 are PhDs in primary care disciplines. Of the 12 MDs, 11 presently practice in medically underserved areas and have academic positions in primary care.