Incorporating Community Engagement in Primary Care Research Training: Eleven-Year Outcomes

BACKGROUND

In response to a local workforce need for community-engaged scholars, a community-based participatory research (CBPR) curriculum was incorporated into an established primary care research fellowship. The program prepares researchers to partner with at-risk communities to address root causes and cultural, linguistic, and systems barriers that contribute to health disparities.

OBJECTIVES

To describe the context, design, implementation and evaluation of the Academic Fellowship in Primary Care and Community-Engaged Research.

METHODS

The traditional primary care research curriculum was enhanced with expanded enrollment, including social scientists with complementary expertise to physician fellows; a structured CBPR seminar series; involvement of fellows in mentored community-academic partnership projects with progression to independence; and relevant teaching and mentoring experiences.

EVALUATION

Between 2007 and 2016, 22 fellows enrolled, with 16 in the CBPR track. Fellows demonstrated significant prepost gain in self-assessed competency in CBPR. During their 2- to 3-year training period, each CBPR fellow developed at least one community-academic partnership project, and they collectively produced more than 50 articles and 70 regional or national presentations, and mentored 29 medical student projects. Graduates have assumed leadership positions in academia, and have improved institutional capacity for community-engaged research, teaching, and practice.

CONCLUSIONS

Important factors related to success and feasibility of CBPR training within a 2- to 3-year timeframe were having dedicated, experienced faculty mentors with existing authentic, trusted community partners, and dedicated funding for new community-academic partnership projects. This model can prepare primary care researchers and teachers to genuinely collaborate with vulnerable communities to address important health priorities and advance health equity.

The Effectiveness of Educational Programs to Improve Recognition and Reporting of Elder Abuse and Neglect: A Systematic Review of the Literature

Health professionals often lack adequate protocols or knowledge to detect, manage, and prevent elder maltreatment. This systematic review describes and evaluates existing literature on the effectiveness of educational interventions to improve health professionals' recognition and reporting of elder abuse and neglect. Fourteen articles described 22 programs ranging from brief didactics to experiential learning and targeted a variety of health and social service audiences. Most evaluations were limited to satisfaction measures. These programs may result in increased awareness, collaboration, and improved case finding. However, using the published literature to guide new program planning is constrained by lack of details and limited evaluations.

Needs Assessment for Creating a Patient-Centered, Community-Engaged Health Program for Homeless Pregnant Women

Purpose

Women who experience homelessness during pregnancy have poorer birth outcomes than the general population. This exploratory research describes the needs assessment of homeless women currently living at a shelter in Milwaukee, Wisconsin, to identify unmet needs related to maternal and infant perinatal health as the first step in designing a mutually beneficial patient-centered service-learning program for medical students to address these needs.

Methods

Two 1-hour focus groups were held at a shelter for women who are homeless and/or victims of domestic violence. A total of 13 women participated in each session; four medical students and a physician served as facilitators and scribes at each session. The facilitators alternated asking predetermined open- and close-ended questions, followed by discussion among participants. Questions elicited experiences during pregnancy, what went well, what women living in the shelter struggled with, and what support they wished for but did not have. Scribes captured the conversation through hand-written notes and used content analysis in order of frequency.

Results

Thirteen themes were identified. The 5 most frequently identified themes were a need for pregnancy education, access/transportation, baby care, advocacy, and material necessities. Participating shelter residents and the medical students expressed interest in working with one another and forming a long-term partnership with the shelter.

Conclusions

Results of this needs assessment will inform the creation of a new shelter-based medical education program that will meet homeless women's needs while preparing medical students for patient-centered, community-responsive care.

Diabetes and hypertension prevalence in homeless adults in the United States: a systematic review and meta-analysis

We estimated hypertension and diabetes prevalence among US homeless adults compared with the general population, and investigated prevalence trends. We systematically searched 5 databases for published studies (1980-2014) that included hypertension or diabetes prevalence for US homeless adults, pooled disease prevalence, and explored heterogeneity sources. We used the National Health Interview Survey for comparison. We included data from 97366 homeless adults. The pooled prevalence of self-reported hypertension was 27.0% (95% confidence interval=23.8%, 29.9%; n=43 studies) and of diabetes was 8.0% (95% confidence interval=6.8%, 9.2%; n=39 studies). We found no difference in hypertension or diabetes prevalence between the homeless and general population. Additional health care and housing resources are needed to meet the significant, growing burden of chronic disease in the homeless population.

An analysis of elder abuse rates in Milwaukee County

INTRODUCTION

The elder abuse and neglect burden in Milwaukee County, Wisconsin, is substantial, with 3384 reports made from 2006 to 2009. Current prevalence estimates are determined from reported cases only and are likely underestimated. Provider awareness of victim and perpetrator characteristics is necessary to increase recognition and response.

METHODS

A cross-sectional analysis of elder abuse and neglect cases reported to the Milwaukee County Department on Aging (MCDA) from 2006 to 2009 was performed to provide a profile of the county's elder abuse burden by victim, perpetrator, and reporter characteristics. Annual reporting trends were identified using Poisson regression analysis.

RESULTS

Fifty-eight percent of MCDA reports of abuse were substantiated after investigation. Victims in Milwaukee County tended to be older than 75 (64%), female (64%), and white (62%). Reporting rates to the MCDA were significantly lower in 2009 than 2006. Perpetrators were often adult children (48%) or a spouse (14%). Forty percent of life-threatening cases of self-neglect were due to unfulfilled medical needs. Most reports were made by medical professionals (23%), relatives of the victim (21%), and community agencies (18%). Only 13% of elder abuse victims were placed in nursing homes and assisted living centers; many received services to assist independent living.

DISCUSSION

Although this study is limited to reported cases only, it provides a valuable profile of pertinent elder abuse characteristics in Milwaukee County.

CONCLUSION

Characteristics of vulnerable elders, potential abusers, and investigation outcomes are described to inform clinical practice about this important social issue.

The urban and community health pathway: preparing socially responsive physicians through community-engaged learning

One of five options for the new required Medical College of Wisconsin Pathways program, the Urban and Community Health Pathway (UCHP), links training with community needs and assets to prepare students with the knowledge, skills, and attitudes to provide effective care in urban, underserved settings; promote community health; and reduce health disparities. Students spend at least 10 hours per month on pathway activities: 4 hours of core material delivered through readings, didactics, case discussions, and site visits; and at least 6 hours of experiential noncore activities applying core competencies, guided by an Individualized Learning Plan and faculty advisor. Noncore activities include community-engaged research, service-learning activities or other relevant experiences, and submission of a synthesis paper addressing pathway competencies. The first cohort of students began their pathways in January 2010. Of 560 participating students, 95 (of which 48 were first-year, 21 second-year, and 26 third-year students) selected UCHP. Core sessions focused on public health, social determinants, cultural humility, poverty, the local healthcare system, and safety net. During noncore time, students engaged in projects addressing homelessness, obesity, advocacy, Hmong and Latino health, HIV, asthma, and violence prevention. Students enjoyed working with peers across classes and favored interactive, community-based sessions over didactics in the classroom. Students' papers reflected a range of service and scholarly activities and a deepened appreciation of social and economic influences on health. The UCHP enriches the traditional curriculum with individualized, community-based experiences to build knowledge about health determinants and skills in partnering with communities to improve health.

Clinical inquiries. What lifestyle changes should we recommend for the patient with newly diagnosed hypertension?

Hypertensive patients should reduce sodium intake (strength of recommendation [SOR]: A). The Dietary Approaches to Stop Hypertension diet (DASH diet)--with salt restriction and increased fruit, vegetable, calcium, and potassium intake-reduces blood pressure and should be recommended (SOR: A). Aerobic exercise is effective in the general, as well as elderly, populations for reducing blood pressure (SOR: A). Patients should be encouraged to reduce alcohol consumption (SOR: A). Evidence that weight loss is significantly associated with blood pressure reduction is inconclusive (SOR: C). Smoking cessation should be encouraged for all hypertensive patients for prevention of cardiovascular disease (SOR: A).

Excess mortality caused by medical injury

PURPOSE

We wanted to estimate excess risk of in-hospital mortality associated with medical injuries identified using an injury surveillance system, after controlling for risk of death resulting from comorbidities.

METHODS

The Wisconsin Medical Injuries Prevention Program (WMIPP) screening criteria were used to identify medical injuries, defined as "any untoward harm associated with a therapeutic or diagnostic healthcare intervention," among discharge diagnoses for all 562,317 patients discharged from 134 acute care hospitals in Wisconsin in 2002. We then derived estimates for crude and adjusted relative risk of in-hospital mortality associated with the presence of a medical injury diagnosis. Logistic regression adjusted for baseline risk of mortality using a comorbidity index, age, sex, Diagnosis Related Groups, hospital characteristics, and clustering within hospital.

RESULTS

There were 77,666 discharges that met WMIPP criteria for at least 1 medical injury (13.8%). Crude risk ratios for death ranged from 1.27 to 2.4 for those with medical injuries within 1 of 4 categories: drugs/biologics; devices, implants, and grafts; procedures; and radiation. After adjustment, estimates of excess mortality decreased, and significance persisted only for injuries related to procedures (39%; 95% confidence interval [CI], 28%-52%) and devices, implants, and grafts (16%; 95% CI, 3%-30%).

CONCLUSIONS

Estimates of excess mortality that do not account for baseline mortality risk may be exaggerated. Findings have implications for the care family physicians provide in the hospital and for the advice they give their patients who are concerned about the risks of hospitalization.

Clinical inquiries. What is appropriate management of iron deficiency for young children?

Infants and toddlers with suspected iron-deficiency anemia should begin treatment with oral ferrous sulfate (3 mg/kg/d of elemental iron). A rise in hemoglobin >1 g/dL after 4 weeks supports the diagnosis of iron deficiency, and supplementation should continue for 2 additional months to replenish iron stores. Recheck hemoglobin at the end of treatment and again 6 months later (strength of recommendation [SOR]: C, based on expert opinion). For primary prevention, counsel parents on the use of iron-fortified formula for non-breastfed infants until the age 12 months (SOR: B, based on randomized controlled study), and introduce iron-rich foods between 4 and 6 months to breastfed babies (SOR: C, based on expert opinion).

Should patients with coronary disease and high homocysteine take folic acid?

All patients with known coronary artery disease should take prescription strength (1 mg/d) folic acid, vitamin B12 (400 microg/d), and vitamin B6 (10 mg/d), which have few if any known adverse effects. In this study, therapy to reduce homocysteine levels with prescription strength folic acid (1 mg) and vitamins B12 and B6 for 6 months following coronary angioplasty reduced the risk of need for revascularization of target lesions and of overall adverse cardiac events at least 6 months following cessation of therapy. Based on this study, it is unknown whether the benefit is related to baseline homocysteine levels or whether there is further benefit to continuing treatment beyond 6 months. Over-the-counter folic acid supplements (800 microg or less) were not studied and may not be as beneficial.

Cancer recurrence and mortality in women using hormone replacement therapy: meta-analysis

OBJECTIVES

We compared the risk of cancer recurrence and all-cause mortality among users and nonusers of estrogen replacement therapy (ERT) after the diagnosis of breast cancer.

STUDY DESIGN

This was a systematic review of original research. Eligible studies were reviewed by 2 investigators who independently extracted data from each study according to a predetermined form and assessed each study for validity on standard characteristics. Meta-analyses were performed with Review Manager 4.1 to provide a summary of relative risks of cancer recurrence and mortality.

POPULATION

Studies included 717 subjects who used hormone replacement therapy (HRT) at some time after their diagnosis of breast cancer, as well as 2545 subjects who did not use HRT.

OUTCOMES MEASURED

Outcomes included breast cancer recurrence and all-cause mortality.

RESULTS

Nine independent cohort studies and one 6-month pilot randomized controlled trial were identified. Studies were of variable quality. Breast cancer survivors using ERT experienced no increase in the risk of recurrence compared with controls (relative risk, 0.72; 95% confidence interval, 0.47-1.10) and had significantly fewer deaths (3.0%) than did the nonusers (11.4%) over the combined study periods (relative risk, 0.18; 95% confidence interval, 0.10-0.31). All tests for heterogeneity were nonsignificant.

CONCLUSIONS

Although limited by observational design, existing research does not support the universal withholding of ERT from well-informed women with a previous diagnosis of low-stage breast cancer. Long-term randomized controlled trials are needed.

Does oral creatine supplementation improve strength? A meta-analysis

OBJECTIVES

Oral creatine is the most widely used nutritional supplement among athletes. Our purpose was to investigate whether creatine supplementation increases maximal strength and power in healthy adults.

STUDY DESIGN

Meta-analysis of existing literature.

DATA SOURCES

We searched MEDLINE (1966-2000) and the Cochrane Controlled Trials Register (through June 2001) to locate relevant articles. We reviewed conference proceedings and bibliographies of identified studies. An expert in the field was contacted for sources of unpublished data. Randomized or matched placebo controlled trials comparing creatine supplementation with placebo in healthy adults were considered.

OUTCOMES MEASURED

Presupplementation and postsupplementation change in maximal weight lifted, cycle ergometry sprint peak power, and isokinetic dynamometer peak torque were measured.

RESULTS

Sixteen studies were identified for inclusion. The summary difference in maximum weight lifted was 6.85 kg (95% confidence interval [CI], 5.24-8.47) greater after creatine than placebo for bench press and 9.76 kg (95% CI, 3.37-16.15) greater for squats; there was no difference for arm curls. In 7 of 10 studies evaluating maximal weight lifted, subjects were young men (younger than 36 years) engaged in resistance training. There was no difference in cycle ergometer or isokinetic dynamometer performance.

CONCLUSIONS

Oral creatine supplementation combined with resistance training increases maximal weight lifted in young men. There is no evidence for improved performance in older individuals or women or for other types of strength and power exercises. Also, the safety of creatine remains unproven. Therefore, until these issues are addressed, its use cannot be universally recommended.

Personal digital assistant for "real time" assessment of women's health in the clinical years

OBJECTIVE

To assess in "real time" the degree to which women's health competencies are addressed in the clinical curriculum by using a personal digital assistant.

STUDY DESIGN

Competencies for women's health were developed. Twelve students were supplied with a personal digital assistant, pre-loaded with a patient log system, for use in assessment of the inclusion of these competencies in the clinical arena. The students received instruction on completing the log for each patient for whom they were primarily responsible.

RESULTS

There were 2690 total encounters. In clerkships other than obstetrics and gynecology, gender was discussed in 10% to 20% of encounters. Other than obstetrics and gynecology diagnostic categories, no more than 15% of diagnoses included gender discussion.

CONCLUSION

Student recording of patient encounters reveals a minimal amount of women's health discussion in the clinical years; however, the personal digital assistant is an effective tool with which to monitor curriculum content in the clinical setting.

A longitudinal women's health curriculum: a multi-method, multiperspective needs assessment

OBJECTIVES

To define critical competencies in women's health for medical student education and to assess the degree to which they are taught.

STUDY DESIGN

A set of competencies in women's health was developed. A multi-method needs assessment was implemented.

RESULTS

Faculty and student evaluations revealed no major areas of disagreement but did identify major deficits in the basic sciences including the physiologic influence of estrogen on nongynecologic organ systems and of androgen on various organ systems, nutrition, and alternative medicine and the difference between the sexes in disease processes, presentation, and treatment. In the clinical years, there are important deficits in the teaching of diseases unique to women, limited attention to psychosocial aspects of women's health, and no cohesive teaching of a gender-specific approach to clinical evaluation.

CONCLUSION

In the medical school curriculum, gender's effect on disease is inadequately addressed. An integrated longitudinal approach to gender-specific medicine is needed.

Management of Helicobacter pylori infection

Helicobacter pylori is the cause of most peptic ulcer disease and a primary risk factor for gastric cancer. Eradication of the organism results in ulcer healing and reduces the risk of ulcer recurrence and complications. Testing and treatment have no clear value in patients with documented nonulcer dyspepsia; however, a test-and-treat strategy is recommended but for patients with undifferentiated dyspepsia who have not undergone endoscopy. In the office setting, initial serology testing is practical and affordable, with endoscopy reserved for use in patients with alarm symptoms for ulcer complications or cancer, or those who do not respond to treatment. Treatment involves 10- to 14-day multidrug regimens including antibiotics and acid suppressants, combined with education about avoidance of other ulcer-causing factors and the need for close follow-up. Follow-up testing (i.e., urea breath or stool antigen test) is recommended for patients who do not respond to therapy or those with a history of ulcer complications or cancer.

Self-rated health status: a new vital sign for primary care?

Self-reported health status ratings depend on whether one references health problems or health behaviors. Pessimistic health perceptions may indicate underlying emotional distress or predict mortality. This study explores the association between a single-item health status question and self-reported health problems or behaviors among women in a Wisconsin family medicine clinic. All women who present for health maintenance complete a health history form that includes a single item health status rating. Health status ratings from 251 randomly selected records were compared with certain reported demographics, health behaviors (e.g. smoking, exercise), health concerns, depression and anxiety symptoms, vital signs and body mass index. Health status ratings of fair or poor were found to be associated with race, marital and employment status, obesity, exercise, and depressive symptoms. Smokers were 4.22 times more likely to report a less favorable health category than non-smokers. Implications for future research are discussed.

Bacterial vaginosis in pregnancy and the risk of prematurity: a meta-analysis

OBJECTIVE

We conducted this meta-analysis to determine the magnitude of risk conferred by bacterial vaginosis during pregnancy on preterm delivery.

SEARCH STRATEGY

We selected articles from a combination of the results of a MEDLINE search (1966-1996), a manual search of bibliographies, and contact with leading researchers.

SELECTION CRITERIA

We included case control and cohort studies evaluating the risk of preterm delivery, low birth weight, preterm premature rupture of membranes, or preterm labor for pregnant women who had bacterial vaginosis and those who did not. DATA COLLECTION AND ANALYSIS. Two investigators independently conducted literature searches, applied inclusion criteria, performed data extraction, and critically appraised included studies. Summary estimates of risk were calculated as odds ratios (ORs) using the fixed and random effects models.

MAIN RESULTS

We included 19 studies in the final analysis. Bacterial vaginosis during pregnancy was associated with a statistically significant increased risk for all outcomes evaluated. In the subanalyses for preterm delivery, bacterial vaginosis remained a significant risk factor. Pooling adjusted ORs yielded a 60% increased risk of preterm delivery given the presence of bacterial vaginosis.

CONCLUSIONS

Bacterial vaginosis is an important risk factor for prematurity and pregnancy morbidity. Further studies will help clarify the benefits of treating bacterial vaginosis and the potential role of screening during pregnancy.

Published literature on faculty development programs

BACKGROUND AND OBJECTIVES

Published faculty development program evaluation articles often leave the program description incomplete, making it difficult for new program planners to build on previous work. Using a model based on the work of Stuffelbeam, we examined faculty development literature for the inclusion of important program elements. We found that many important program components, including local needs assessment, leadership and resource support, stakeholder input, implementation barriers, participant attendance, and cost were each discussed in fewer than 30% of published articles. The context, input, process, and product framework is proposed as a guiding model for future program reports.

A profile of family medicine scholarship 1978-1995: an analysis of national presentations

BACKGROUND AND OBJECTIVES

Presentations at the annual meetings of the Society of Teachers of Family Medicine were analyzed to determine trends in the content of the work and the types of work represented.

METHODS

All program presentations from 1979, 1986, and 1993-1995 were analyzed. Content classifications were based on historic analyses of family medicine literature. Classifications of types of scholarship came from a 1990 Carnegie Foundation report, Scholarship Reconsidered: Priorities of the Professoriate.

RESULTS

Results showed that a wide variety of scholarly activities were presented, but application of educational work was predominant. Many presentations crossed interdisciplinary boundaries, including behavioral science, faculty development, and health services.

CONCLUSIONS

Contributions of family medicine scholarship may be applicable to other medical fields. The variety of family medicine scholarship may warrant a redefinition of reward systems for faculty.

The state of the literature on primary care specialty choice: where do we go from here?

A large body of research on medical students' choice of primary care specialties has been published. However, the literature is difficult to interpret because of multiple biases, design weaknesses, small numbers of subjects, inconsistencies in both dependent and independent variables, and conflicting results. These weaknesses have been noted by authors who have reviewed the work in this area, but the authors have given little direction for ways to improve and build upon the current state of the literature. This paper provides a quantitative description of the content of the specialty choice literature. As part of a larger project that included an exhaustive literature analysis, all research on primary care specialty choice published between 1987 and 1993 was collected and summarized according to study questions, designs, data sources, samples, theory, and outcome variables. Portions of this information were used to rate the quality of each study, yielding a score from zero to 100 that indicated the trustworthiness of the study's conclusions. Overall, the studies examined were found to use predominantly cross-sectional designs and to lack theoretical basis. Special curricular tracks, student personality, and self-reported influences were the most frequently studied determinants of primary care specialty choices. The results confirm previous qualitative descriptions of the state of the literature on specialty choice, and lead to recommendations for approaches to improve the quality of further work in this area. The research agenda that emerged from the larger project is also presented.

A systematic approach to conducting a non-statistical meta-analysis of research literature

Literature analyses and syntheses are becoming increasingly important as a means of periodically bringing coherence to a research area, contributing new knowledge revealed by integrating single studies, and quickly informing scientists of the state of the field. As a result, there is a need for approaches that can provide replicable, reliable, and trustworthy results. Over the last decade many researchers have begun using the statistical meta-analysis approach to integrate studies. However, the single studies conducted in many areas are not of the type amenable to statistical meta-analysis but are more appropriate for non-statistical analysis and synthesis. The present paper describes (1) a rigorous approach to conducting a non-statistical meta-analysis of research literature and (2) an example of how this approach was applied to the literature of determinants of primary care specialty choice published between 1987 and 1993. This approach includes model development, literature retrieval, literature coding, rating references for quality, annotating high-quality references, and synthesizing only the subset of the literature found of sufficient quality to be considered. Also, the basic results of each included study are reported in the synthesis so that readers have before them all the "data points" used in the synthesis. Thus, readers can draw their own interpretations without having to re-collect the data, just as they would be able to do in any single study that presents original data as well as conclusions and discussion.

Determinants of primary care specialty choice: a non-statistical meta-analysis of the literature

This paper analyzes and synthesizes the literature on primary care specialty choice from 1987 through 1993. To improve the validity and usefulness of the conclusions drawn from the literature, the authors developed a model of medical student specialty choice to guide the synthesis, and used only high-quality research (a final total of 73 articles). They found that students predominantly enter medical school with a preference for primary care careers, but that this preference diminishes over time (particularly over the clinical clerkship years). Student characteristics associated with primary care career choice are: being female, older, and married; having a broad undergraduate background; having non-physician parents; having relatively low income expectations; being interested in diverse patients and health problems; and having less interest in prestige, high technology, and surgery. Other traits, such as value orientation, personality, or life situation, yet to be reliably measured, may actually be responsible for some of these associations. Two curricular experiences are associated with increases in the numbers of students choosing primary care: required family practice clerkships and longitudinal primary care experiences. Overall, the number of required weeks in family practice shows the strongest association. Students are influenced by the cultures of the institutions in which they train, and an important factor in this influence is the relative representation of academically credible, full-time primary care faculty within each institution's governance and everyday operation. In turn, the institutional culture and faculty composition are largely determined by each school's mission and funding sources--explaining, perhaps, the strong and consistent association frequently found between public schools and a greater output of primary care physicians. Factors that do not influence primary care specialty choice include early exposure to family practice faculty or to family practitioners in their own clinics, having a high family medicine faculty-to-student ratio, and student debt level, unless exceptionally high. Also, students view a lack of understanding of the specialties as a major impediment to their career decisions, and it appears they acquire distorted images of the primary care specialties as they learn within major academic settings. Strikingly few schools produce a majority of primary care graduates who enter family practice, general internal medicine, or general practice residencies or who actually practice as generalists. Even specially designed tracks seldom produce more than 60% primary care graduates. Twelve recommendations for strategies to increase the proportion of primary care physicians are provided.

Influence of medical school curriculum on primary care specialty choice: analysis and synthesis of the literature

There is a growing consensus that the proportion of primary care physicians in the United States is inadequate to meet health care needs. Many graduating medical students continue to choose to subspecialize. The literature on curriculum and specialty choice is fraught with confounders and a lack of randomized trials, and recommendations for strategies to increase the production of generalists have not been based on clear evidence that the interventions will be effective, thus making it difficult for medical schools to react responsibly to these recommendations. To assist educators and policymakers in their efforts to produce more generalists, the author critically reviewed the literature on curriculum and primary care specialty choice from 1982 through April 1993. A literature search was conducted using the MEDLINE, Educational Resources Information Center, and PsychInfo databases. Of more than 150 studies found in the search, 31 were determined to be relevant and to meet inclusion criteria. The results confirm that the determinants of specialty choice are multifactorial and that there are many weaknesses in the published literature, making interpretation difficult. Important trends did emerge, however, providing direction for intervention and recommendations for further investigation. The evidence suggests that three types of curricular experiences may increase interest in primary care: third-year required family medicine clerkships (especially those that are six, rather than four, weeks long), continuity experiences in primary care settings, and, most promising of all, primary care tracks.