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Global hr forum2008-ronald cervero-integrating physicians’judgments & social systems in practice-based medical education
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Global hr forum2008-ronald cervero-integrating physicians’judgments & social systems in practice-based medical education


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  • 1. Integrating Physicians’ Judgments & Social Systems in Practice- Based Medical Education Ronald M. Cervero University of Georgia Lifelong Education, Administration, & Policy
  • 2. “Attempts to change clinical practice tend to be successful only to the extent that they recognize and engage actively with the real world in which clinicians operate.” Eve, Golton, Hodgkin, Munro, & Musson, 1996
  • 3. Objectives n Historical development of practice-based continuing medical education n Improving physicians’ clinical judgments in social systems n Four lessons for improving practice-based medical education
  • 4. Practice-Based Medical Education n Content model: What physicians learn (??? to present) n Process model: How physicians learn (1960s to present) n Contextual model: Where physicians learn (1990s to present)
  • 5. Content Models in Medical Education “When most people in health care think of CME, they think of a large room full of physicians who have taken time off from their busy practices to listen to a series of speakers who lecture them about the most recent advances in their respective fields. …Almost all of contemporary CME takes place in this way.” (Moore, Green, Jay, Lesit, & Maitland, 1994)
  • 6. Process Models in Medical Education “ What then is the problem? Any careful review of continuing medical education in the United States today will lead inexorably to the conclusion that most programs are based on a categorical content model…it would seem that the time has come to try a different educational model—one built upon solid evidence about the way adult learn rather than the long-honored methods of teaching them. There is ample evidence to support the view that adult learning is not most efficiently achieved through systematic subject instruction; it is accomplished by involving learners in identifying problems and seeking ways to solve them.” ( Miller, 1967)
  • 7. Practice-Based Models Across Continuum of Medical Education n Medical Schools: Problem-Based Curricula n Residencies: 1 of 6 core competencies is “practice-based learning and improvement” (Accreditation Council on GME) n Continuing Education: Providers “must promote professional activities for physicians to systematically learn from their clinical experience” (American Association of Medical Colleges)
  • 8. Where Physicians Learn Practice-Based Medical Education Should Seek to Improve Physicians’ Clinical Judgments In Social Systems
  • 9. Why Clinical Judgments Matter in Medical Care “Few doctors are now inclined to think of themselves as simply arriving at logically determined conclusions by applying scientifically tested truths to experimentally derived data…Considerations of many kinds are often jumbled together to form a picture full of uncertainties, requiring the most delicate kinds of judgments and intuitions.” (Bok, 1984; Harvard Medical School)
  • 10. Why Social Systems Matter in Medical Care “At least 44,000 people …die in hospitals each year as a result of medical errors that could have been prevented” (IOM, 1999). “The concept that bad systems, not people, lead to the majority of errors and injuries…has become a mantra in health care.” (Leap & Berwick, 2005)
  • 11. Changing Physicians’ Practices: What Do We Know? n There are no magic bullets, although there are many effective strategies. n Strategies do not always work because physicians practice in a complex social network that defies single interventions for universally shaping practice patterns. n Any change strategy must assume physicians’ clinical judgments are enabled and constrained by system dimensions of the work context.
  • 12. System Effects on Physicians’ Clinical Judgments n Patient-Physician Interaction n Clinical Environment n Physician’s Relationships with Colleagues n Political-Economic Regulatory systems n Reimbursement Systems
  • 13. Lesson 1 Place-Based Reflective Practice In order to improve physicians’ clinical judgments, educational interventions should allow physicians to reflect on real-time interactions with patients in the presence of people from their geographically- defined or professionally-defined systems of practice.
  • 14. Lesson 2 Learning for System Improvement In order to improve the systems in which physicians practice, educational interventions should provide ways for physicians and other members of the office staff and health-care team providing care to reflect on ways that organizational processes enable and constrain effective medical practice.
  • 15. Lesson 3 Focus on Quality Improvement Integrate practice-based education with quality improvement initiatives of health care organizations to provide relevant training at the appropriate stages of those processes.
  • 16. Lesson 4 Credential for Learning Policymakers responsible for licensing, certification, and accreditation need to develop systems that move from accumulating credits to rewarding effective practice-based individual and system learning.