Sixteen-year longitudinal evaluation of a community-oriented primary care curriculum

Using outcome criteria, we assessed the quality of a medical school educational programme designed to produce physicians who would practise primary care in medically underserved communities. The curriculum included early exposure to primary care through a preceptorship programme, courses in epidemiology and community health, and community-based clinical primary care clerkships. The evaluation focused particularly on changes in career plans between entry and graduation; we continued to follow the graduates until they established their practices. We report on eight cohorts of students (N = 261) who entered medical school between 1978 and 1985. At admission 69% or more of each cohort (78% mean) planned careers in primary care. At graduation, this percentage had decreased to 53-65% (mean 58%). Of all graduates, 57% ultimately established a primary care practice. About 45% of students (based on two cohorts) expressed an intent at admission to practise in a medically underserved community; at graduation and in practice this figure had risen to over 80%. These data are quite favourable when compared with the United States norm. These findings suggest that the approach used in this curriculum can yield substantial numbers of primary care physicians. Caution should be exercised in interpreting the findings, however, because of factors such as confounders (i.e. non-curricular factors) and self-selection bias. Problems such as these threaten the validity of most published studies on this topic.