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  1. 1. Joint Educational Program of the AMA Council on Medical Education and Section on Medical Schools Presentation Summaries June 17-18, 2005 Introductory Remarks Sandra F. Olson, MD Chair, AMA Council on Medical Education It was just last year that the Council on Medical Education celebrated its 100th anniversary with a joint Council and Section program highlighting how far we have come in medical education. The medical school curriculum has moved from students being passive observers in the hospital – if they were permitted in the hospital at all – to students being full and valued members of the health care team. We have added new subject areas to the curriculum and developed new evaluation formulas to determine if the students have learned. Our system of graduate medical education and continuing medical education are products of the past century, as is our system for assuring that physicians not only acquire but maintain competence. Although our current educational model gives us a lot to be proud of, we have concerns with it that need to be discussed. This joint educational program will try to identify those concerns and discuss remedies. The agenda will require cooperation and collaboration among a wide variety of individuals and groups. Session Moderator Ann C. Jobe, MD, MSN Chair, AMA Section on Medical Schools The education community goes in cycles, initiating calls to action, talking about reforms, and issuing reports, such as the Association of American Medical Colleges’ “Physicians for the 21st Century–The GPEP Report” in 1984 and the AAMC’s “Educating Medical Students – ACME-TRI Report” in 1992. We talk about things, and then we need to move ahead. We will start this discussion by comparing our educational system to the real world, so that we can reflect on what we need to do. Reality Check: From the Real World of Health Care Speaker Elliot J. Sussman, MD President and CEO Lehigh Valley Hospital and Health Network Teaching operates best in a smoothly functioning clinical environment that is centered in the real world. That means focusing on the patient. “What do your patients want?” is constantly asked at Lehigh Valley Hospital, a 610-bed teaching hospital in Allentown, Pa., with a strong commitment to providing free care to low-income patients. It is a big challenge. National surveys show that up to 55% of Americans are dissatisfied with their care—up significantly from five years ago. One-third say that they have been involved in medical errors. People are also better informed because they can consult Web-based data. Many patients probably still want to be told what to do, but that’s not something we should encourage, and that attitude is changing. Specifically, patients and their families want: • A clean, comfortable and safe environment; • An informed and competent staff in sufficient numbers, especially of nurses;
  2. 2. CME/SMS Presentation Summaries June 17-18, 2005 Page 2 • Involvement in decisions on their care; • Transparency, so that they can understand their care; and • Safety and quality. Some things they want may seem to be beside the point, such as food services, but Lehigh Valley takes this very seriously because it contributes to the patient’s experience. The hospital just switched to individual ordering of meals, with delivery guaranteed in 45 minutes of the desired time. Since then, satisfaction scores have risen dramatically while food costs have gone down. A lot of work still needs to be done to meet patients’ needs. Hospitals deliver appropriate base-care for the 12 most common medical conditions only about half the time. They got it right barely in the double-digits for some common conditions, according to a review by Carolyn M. Clancy, MD, director of the U.S. Agency for Health Care Policy and Research. A decade ago, Lehigh Valley totally reorganized itself around patient-centered care. Nurses at most hospitals spend only about 10% of their time at the bedside, but we switched our nurses to spend 50% of their time at the bedside. Despite some staffs’ fears of the changes, clinical outcomes and patient satisfaction rose and nosocomial infection and bedsore rates dropped. These changes are often hard on physicians. All our staff, including physicians, are expected to learn a team approach. This has been one of the most difficult changes to make. Doctors have had to learn a whole new set of skills. Teamwork can be instilled through personal example and formal work in communication that stresses active listening. Also, physicians have been switching to computer- assisted physician order entry, which can improve safety by replacing illegible handwriting and oral miscommunication. Our medical staff has agreed to enter almost every order electronically by the end of this year. Doctors who continue to call in verbal orders will be put into remediation and could lose their privileges if the problem is not resolved. Lehigh Valley has also introduced bar coding for supplies and intensivists to cover 100 ICU beds. We started a full-time intensivist program in 1998 and now have centralized electronic coverage from 7 pm to 7 am every day. The service may be extended to other hospitals and run around the clock. Other ways to advance safety are frequent hand-washing and perhaps even eliminating neckties in the hospital. Doctors and trainees need to learn systems and processes that make the hospital more efficient. Everyone in the hospital needs to be concerned about value. Measurements of our progress, as compared to benchmark data for similar teaching hospitals, are very important to us. A little over a decade ago, Lehigh Valley’s costs were well above the median for similar hospitals. It took seven years to pull the rate below the median and we have stayed there for the past four years. Improving efficiency can be about mundane things, such as aiming to have a bed cleaned in 61 minutes rather than three hours. The emergency department aimed to reduce the time it takes for a patient to see a doctor to at least 20 minutes and to reduce the total time they spend in the ED by more than an hour. The work has paid off. We have raised patient satisfaction measures from the 25th percentile to above the 97th percentile. The hospital values teaching and cooperates with ongoing educational reforms. Changes in ACGME rules require careful attention, but we gladly bear the added costs because they improve the educational enterprise. However, a lot can be done without spending money. Attending physicians respond very well to appreciation, and they can be used as role models in both inpatient and
  3. 3. CME/SMS Presentation Summaries June 17-18, 2005 Page 3 outpatient settings. Lehigh Valley is participating in the Academic Chronic Care Collaborative run by the AAMC Institute for Improving Clinical Care. The Institute for Healthcare Improvement, another organization for improving hospital outcomes, is undertaking similar initiatives. Just as in clinical care, human organizations and structures metabolize. It is necessary. Initiatives always need a push forward, but too much change can be overwhelming. A key function of both the art of medicine and the art of management is setting the right pace. Speaker Walter J. McDonald, MD Executive Vice President, Council of Medical Specialty Societies (CMSS) It has always been a challenge to figure out what should be taught in medical school to meet the skills that students will need in practice many years later. Today, the practice world is changing even more quickly, what with an incredible explosion of information and changes in the delivery of health care. In order to know what to teach, there needs to be a thorough assessment of what needs to be learned. What are the unmet needs that medical students and graduates need to know? We need to know what the average physician does, but our information is sketchy and out-of-date. Several decades ago, the Mendenhall Study monitored what physicians do. It found, for example, that nephrologists saw renal patients about 60% of the time. But that data has never been significantly updated. Now the AAMC is involved in a new study, but it’s going to take a lot of time and money to complete, and this work needs to involve all stakeholders. We need a lot more research in medical education. Until we address this sticky issue, we’re shooting in the dark. The boards have done a pretty good job of defining domains for their particular specialties, and some of the specialty societies have helped. But for the most part, those efforts are incomplete. They need to be constantly revised, and they are not. We will have to look across the continuum of education, including an assessment of the needs of a physician in practice. For continuing medical education (CME), we need to understand how to integrate the practice into education. How do you glean the data to understand what you don’t know? Everyone needs to get comfortable thinking about the continuum of medical education. Learning is a lifelong necessity. Doctors spend four years in medical school and another three to seven in training, but medical careers can be 40 to 50 years long. A lot of practicing physicians don’t understand the need to pursue education after residency, and those who do understand may not ask what skills they lack. Physicians don’t have a lot of spare time for learning. There are some very commendable models in physician self-learning. Concerns about competency stem from the profession’s accountability to society. Our graduates tend to feel entitled and it’s understandable, viewing the time and money they invested in their education. But that entitlement shouldn’t lapse over into arrogance. Physicians are part of a social contract that places expectations on them, such as accountability, safety and quality. They deal with patients who are a lot better informed than before and have higher expectations, so whatever the profession got away with before simply won’t do. Professionalism is not innate. It has to be taught and reinforced. Students may think they know what professionalism is, but they don’t yet understand all of its implications. Educators have to teach it and live it. We don’t want medical students saying, “We learned all our bad habits from you folks.”
  4. 4. CME/SMS Presentation Summaries June 17-18, 2005 Page 4 Medicine is very large, very important and very expensive, but many practicing physicians still regard it as a mom-and-pop operation. That thinking leads to a fragmented profession with a weakened voice. Policymakers want to know, “What does Medicine think?” The answer often is that urologists think one way and gynecologists another. With all these fragmented interests, it’s going to be hard to bring together the various stakeholders to reform the whole continuum of medical education, but it must be done. Fragmentation is no good for anybody, because it prevents young physicians from getting involved. The myriad organizations just make them shake their heads. In clinical departments under pressure to provide services and generate revenue, teaching is often seen as a distraction. It’s amazing how many teaching physicians have no training at all in teaching. Teachers are made, not born. Just a little bit of teacher-training can make a great difference. We have let ourselves get away from the old adage, “Teach to the practice.” Training in a hospital setting has made internal medicine great hospitalists but hasn’t prepared them enough for the community, where most of them will be going. Ten common conditions make up 40% of the average internist’s practice but they aren’t much taught in the teaching hospital. It is no wonder that when graduates of these programs hang out their shingle, they are sorely disappointed. What they were taught is not what they are doing. Maybe internal medicine training should be made more explicit, with separate tracks for academics, hospitalists, and outpatient care. And maybe the latter track should work more closely with family medicine, which is gradually losing its links to surgery and ob-gyn. Several topics probably need a bigger role in the curriculum. Residents have to understand what money means. Rather than panicking about carrying debts of $120,000 or $150,000, they need to understand how those debts can be paid off in practice. And they also don’t fully understand that health care has become very expensive, and costs are reaching a crisis stage. They don’t know enough about community health, preventive measures, and they don’t seem much interested in treating the elderly. Health care purchasers are very excited about team care, but medical schools still don’t teach much about it. Physicians are losing interest in the history and physical, despite the many values of touching and talking to a patient. These topics have to compete with the “exciting” ones, such as learning about the organs and what makes them fail and work again. Schools have limited time to teach, and physicians in practice also have limited time to learn. Changing all of this won’t be easy, but you can either have very low expectations or very high expectations. Medical educators have to think well ahead of the ball. The anthropologist Margaret Mead said: “We’re now at a point where we must teach our children what no one knew yesterday and prepare our schools for what no one knows yet.” Question and Answer Session Question Dr. Ann Jobe What’s the most frequent type of retraining needed by the new physicians you hire? What areas need to be corrected the most? Dr. Elliot Sussman: New physicians have to learn professionalism. The hospital often has to correct how they interact with non-physicians, including nurses, other caregivers and patients. We need to
  5. 5. CME/SMS Presentation Summaries June 17-18, 2005 Page 5 realize that it’s truly a blessing to be a physician. Senior physicians should be role models, communicating what’s right and what’s wrong, and not tolerating lapses. Dr. Walter McDonald: People who hire new physicians have to spend a lot of time retraining them in outpatient medicine—especially internists and family physicians. Also, new physicians are clueless about how health care is financed and don’t understand their role in controlling costs. Question Peter J. Fabri, MD Member-at-Large, Section on Medical Schools Associate Dean for Graduate Medical Education, University of South Florida College of Medicine If medical students and residents cannot think critically, forgive them, they are only reacting to the world we put them in. As one chief resident once said, “If you think, you’re going to weaken the team.” In his book, “Emotional Intelligence,” Daniel Goleman emphasizes the ability to adapt to change and work as part of a team, but most faculty members can’t do either. Faculty are the chief barriers to reform. How can we change that? Dr. Walter McDonald: Faculty are not always sending the right messages or setting the right examples but they shouldn’t take all the blame. They haven’t been trained to adapt to change or to work as part of a team. It is true, though, that they have an enormous influence. An unpublished study has almost directly linked the moods of house officers to the moods of their attending physicians. Faculty attitudes might change through better rewards for teaching. If not, some students could bypass them and train with community physicians. Dr. Elliot Sussman: Skills like teamwork and adapting to change do not exist in traditional medical schools, but they are elsewhere in the university, in schools of management, psychology and the humanities. Question Mahendr S. Kochar, MD Senior Associate Dean for Graduate Medical Education, Medical College of Wisconsin Heavy subsidies from the pharmaceutical industry exert a tremendous influence over continuing medical education. How can we break away from these influences so that CME is unbiased and physicians can practice evidence-based medicine? Dr. Walter McDonald: Rather than taking the drastic step of cutting off pharmaceutical funding, we need to learn how to handle it correctly. The pharmaceutical industry has accepted guidelines on gift- giving endorsed by the Accreditation Council for Continuing Medical Education. These guidelines put the onus on physicians to make sure there is no bias in the presentation. Physicians have to sign statements that hold them accountable. Dr. Ann Jobe: The old lecture format, which uses the pharmaceutical money, may shrink in importance if CME moves to individual, practice-based research and improvement projects for physicians. Question Michael Reichgott, MD
  6. 6. CME/SMS Presentation Summaries June 17-18, 2005 Page 6 Associate Dean for Clinical Affairs and Graduate Medical Education, Albert Einstein College of Medicine Member of the Liaison Committee on Medical Education When program directors are told they have to assess residents in the ACGME’s six competencies (patient care, medical knowledge, practice-based learning and improvement, interpersonal and communications skills, professionalism, and systems-based practice), their response is, “Why do we have to do this?” It’s awkward to have to say, “Because the ACGME says so.” Are there no positive incentives? Dr. Elliot Sussman: Don’t give up the threats entirely. The best approach is using both “carrots” and “sticks.” The stick might be, “And by the way, you won’t get a paycheck.” And the carrot might be, “Because life will be better.” When an organization undertakes major system change, leadership has to be honest about the hardships and show how physicians’ lives or their patients’ lives will improve. When Lehigh Valley switched to computer-assisted physician order entry, it was clear that physician productivity would drop, so the hospital gave them modest payments and provided decision-support. They appreciated that. Dr. Walter McDonald: Money and promotion are two strong motivators. In academics, just being a good teacher is not adequately recognized, so tying this work to future promotion is a way to make it mean something. Another motivator is one’s sense of professionalism. If people understand their responsibilities as professionals, it’s hard to do the wrong thing. Question Ronald D. Franks, MD Chair-Elect, Section on Medical Schools Dean, East Tennessee State University James H. Quinlan College of Medicine To Dr. McDonald: How will competency-based, outcomes-based CME unfold? What are the requirements going to be? Will both carrots and sticks be built into the incentives to develop the six areas of competencies adopted by the American Board of Medical Specialties in its Maintenance of Certification program? Dr. Walter McDonald: Maintenance of Certification will be a very big stick, because it will be required for recertification in all 24 ABMS specialties. Like it or not, it is coming. Everyone will have to comply, except older physicians who will be grandfathered in. Physicians are grumbling about it. Some doctors in Portland, Ore., let their feelings be known when ABMS President Stephen H. Miller, MD, recently came to town. But among all the big changes, they may find some carrots, too. The new program will, among other things, measure a physician’s clinical outcomes. Doctors get excited about outcomes because it brings out their competitive instincts, according to Brent James, MD, an outcomes researcher at Intermountain Health in Salt Lake City. Now everyone wants to measure outcomes, but the profession has to be vigilant about how this will be done. Question Harry S. Jonas, MD Former Assistant Vice President for Medical Education, AMA Former Dean, University of Missouri-Kansas City School of Medicine
  7. 7. CME/SMS Presentation Summaries June 17-18, 2005 Page 7 Quite a few deans opposed the 1984 GPEP Report, even though many aspects of it were prescient, such as a call to teach information technology. If we issue another report recommending major changes, what is the best way to deal with resistance to change? Dr. Walter McDonald: It will be more difficult to gain approval if the recommendations are costly, take a great deal of time to carry out, and if vested interests oppose them. Many physicians’ groups thrive on controversy, which has the effect of splitting up the House of Medicine. Gastroenterology, for example, has four or five representative groups. If physicians don’t unite behind reforms, there is going to be a price to pay. Consolidation, as the American College of Physicians and American Society of Internal Medicine did in 1998, will make reform more likely and strengthen the voice of the profession. The proliferation of physicians’ groups is marginalizing the whole profession. In the 1940s, a lot of physicians belonged to just one organization, the AMA. The AMA made health policy. Now all kinds of groups, including pharmaceutical companies, health care purchasers and others, help make health policy. Physicians won’t act to end the fragmentation until they understand how marginalized they have become. Dr. Ann Jobe: This conference is an opportunity to bring together physicians who influence each piece of the fragmented whole. Everyone needs to bring their piece to the table and have a conversation, then work on implementation strategies. The AMA-AAMC collaboration agreement, which will be announced tomorrow, is a step in that direction. Both organizations collaborate a lot already, but this agreement makes it explicit. Dr. Walter McDonald: Collaboration has already started in continuing medical education. All of the players have come together and laid out a program for change as the Conjoint Committee on Continuing Medical Education, representing 14 stakeholder organizations, including the AMA and groups as diverse as the Accreditation Council for Continuing Medical Education, Alliance for Continuing Medical Education and Society for Academic Continuing Medical Education. They have agreed to drop their baggage and reform CME before somebody else does. Question Henry S. Pohl, MD Vice Dean for Academic Administration, Albany Medical College The attitudes of the people going into medicine are changing, and changing lifestyle is a key feature. We need to attract people into primary care specialties and we have to deal with shift work. Should we add new training elements to residency programs, such as the concept of hospitalists and the team approach? Dr. Ann Jobe: The ACGME or its residency review committees may want to comment on that. Some RRCs may need to re-examine their requirements. Some rules get in the way of changing practice tracks and of “teaching to the practice”—that is, making sure what is taught matches what we think will be practiced. Comment Richard Allen, MD Past Chair and current member, AMA Council on Medical Education Assistant Dean for Graduate Medical Education, Oregon Health & Science University School of Medicine
  8. 8. CME/SMS Presentation Summaries June 17-18, 2005 Page 8 Initiatives to improve physician competencies offer plenty of positive incentives for doctors. The ACGME is rewarding programs that do a good job teaching the competencies and it hands out the Parker J. Palmer "Courage to Teach" Award to individuals. Under pay-for-performance, Medicare and other payment systems are paying bonuses to physicians who improve quality of care. Of course, it’s a “stick” for those who don’t get the bonus, because the bonus money is usually taken from the pot for all physicians. Those who think ABMS’ Maintenance of Certification program will only amount to more work and more expenses need to understand that this is the right thing to do. The profession is under great pressure to prove competency. We face an extensive patient safety movement, with the press constantly asking why the profession cannot police its own. Every day for the past two weeks, the Portland Oregonian has been reporting on an incompetent physician who fled to Australia after being sanctioned by the Oregon Board of Medical Examiners. Suggestion Judy Jean Chapman Widow of the late John Chapman, MD, former Dean, Vanderbilt School of Medicine; past Chair of the Council on Medical Education; and founder and past chair of the Section on Medical Schools. Medical schools seem to be moving toward specialization, with each school focusing on a particular niche. In view of this trend, it might make sense to develop quality measures for each type of school and assess whether they are meeting their own goals. Dr. Walter McDonald: Medical schools don’t need to be all things to all people. They can’t all be in the top 25 National Institutes of Health grantees. Each school ought to determine what it is best at and what its constituency needs, and then turn out the best doctors it can, based on that. Schools could be recognized as “centers of excellence” in a number of ways. One might be recognized for research grants and another for its popularity with patients. Dr. Ann Jobe: However, all schools need to have a core curriculum of essential components, similar to the core competencies of the ACGME. Once they have the core in place, then they should be given a lot of flexibility to specialize. The AMA Transforming Medical Education Initiative would allow for flexibility. Each school could meet certain special considerations, such as for training research scientists or community-based primary care physicians to serve rural areas. Schools do this already, but there hasn’t been an overall dialog or a concerted effort to make that explicit. Suggestion Aradhana Sood, MD Professor of Psychiatry and Pediatrics at Virginia Commonwealth University Member of the Psychiatry Residency Review Committee, ACGME Medical educators are rediscovering professionalism, humanism and altruism. These were hot topics at the November 2004 meeting of the AAMC. Altruism is frequently a key criterion for acceptance into medical school, but, in many cases, schools then snuff out humanistic interests in their drive to turn out practitioners in the science of medicine. Virginia Commonwealth University is trying to reverse that trend. This year, the school introduced humanism and professionalism as a core competency for first-year medical students. Medical students will be working on humanism with preceptors in small groups, and students and faculty will be graded on this issue. It is time that we apply system-based learning, learning how to interact with other people as human beings and to understand our patients.
  9. 9. CME/SMS Presentation Summaries June 17-18, 2005 Page 9 Dr. Ann Jobe: Educators are acting on this resurgence of humanism and professionalism. Dr. Ronald Franks, a member of the Liaison Committee on Medical Education, is working on an LCME project to examine professionalism and the “hidden curriculum”—the informal influences that might be prompting medical students to abandon humanistic goals. And the Governing Council of the Section on Medical Schools is considering enhancement of professionalism across the continuum as the topic for next year’s educational program. We would be looking at admissions criteria, best practices for teaching programs and how they are working. Dr. Walter McDonald: Some of those applicants who talk about helping people may merely be using empty rhetoric to get into medical school. It’s difficult to know the depth of an applicant’s commitment to altruism. On the other hand, the medical school experience does seem to dampen interest in altruism and professionalism. When students get a taste of clinical care, they often lose interest in learning professionalism. It’s a struggle to create a strong course on professionalism, but it can succeed, and it’s worthwhile work. Younger people seem to have a different take on altruism, centered on their own families. In one study, researchers presented younger and older physicians with test cases in which the doctor has seriously ill patients but is expected to go home to take care of his family. The traditional physician often decides to stay with the patient while the younger one goes home. Question David Musick, PhD Associate Dean for Medical Education, Brody School of Medicine at East Carolina University For Dr. McDonald: The growth of medical organizations seems to be out of control. The Blue Ridge Academic Health Group’s report, “Reforming Medical Education: Urgent Priority for the Academic Health Center in the New Century,” reports that some 400 organizations have something to do with education, accreditation, licensing or otherwise approving the process of becoming a physician. It calls on leaders of academic health centers to help consolidate these organizations so they can be more effective. How do we deal with this problem? Dr. Walter McDonald There are too many medical organizations, though some of them are necessary, such as the ACGME, ACCME, and American Board of Medical Specialties. We can slow the proliferation by not recognizing new ones. Every year, CMSS gets a number of requests for recognition of new groups, such as an organization to accredit CME providers. Most of these organizations are about turf and money. Members of specialty organizations should persuade competing societies to consolidate, as the ACP and ASIM did. But human nature being what it is, organizations will probably continue to be overlapping and fragmented. The American Board of Medical Specialties and most of the specialty boards have done a pretty good job of refusing to recognize new groups, despite great pressures to do so. The next big battle may be the hospitalists applying for recognition from the American Board of Internal Medicine and perhaps from ABMS. Suggestion Mary T. Coleman, MD Associate Dean for Curriculum, University of Louisville School of Medicine The energy of medical students can be unleashed to carry out curricular changes by enlisting them in process-improvement activities. Beginning in their first and second years, students at the University
  10. 10. CME/SMS Presentation Summaries June 17-18, 2005 Page 10 of Louisville work in teams with administration. They help to identify aspects of their education that they’d like to change. The next step is students initiating changes in the clinical practice setting. The problem is we can’t yet give these students longitudinal clinical exposure. Dr. Walter McDonald The longitudinal clinical exposure is absolutely critical and is missing from the whole medical education process. You don’t really experience it until you get into the real world. How to Heal the Medical Education System Speaker Jerome P. Kassirer, MD Distinguished Professor, Tufts University School of Medicine Former Editor-in-Chief, The New England Journal of Medicine What’s wrong with our medical education system? The hospital as human classroom is obsolete. The lecture format is inefficient, unpopular and may be outmoded in the digital age. Student skills of history-taking and the physical exam are suboptimal, and even when they are adequate, they are not well used. Ideal role models are scarce. Disgruntled faculty members often opt out of teaching or expect to be paid for it. Tenure has ossified faculty and stifled educational innovation. Society is demanding new approaches, such as teamwork and error reduction, but most of the schools are deaf to this kind of innovation. Teaching facts still dominates, while teaching clinical cognition still lags. Problem-based learning often focuses on how to find and analyze data, not on how to think about making a diagnosis, or about the trade-offs between the costs of tests and treatments and their benefits. The cost of education is out of control. Students from wealthy families dominate in many medical schools while the rest graduate with huge debts. Everyone learns in a conflicted web of pharmaceutical influence. Countless topics are competing for space in the curriculum, including new advances in science, palliative care, medical ethics, human rights, alternative medicine, teamwork, medical errors, information technology and care of the chronically ill. But despite this curricular logjam, we continue to let students out for summer break. And when students graduate and finish their residency training, the people who employ them are often unhappy with the product. But we also have cause for optimism. The following innovations have shown various degrees of promise: • The academy, an organization that has risen within some universities, fosters teaching abilities and academic growth of faculty. But is there money for it? And can it reward faculty for teaching? Or will it retain the same old barriers between the academics, the researchers and the educators? Is it trying to recreate an imagined ideal path or can it deal with present-day realities? Is it elitist? And can models of the academy at Harvard and the University of Washington be transplanted to other schools? The answer may be no. • Student-centered learning transfers the responsibility for learning from the faculty to the students. Students begin to own their own education, which is a valuable idea. But is student-centered
  11. 11. CME/SMS Presentation Summaries June 17-18, 2005 Page 11 learning being used as an excuse to reduce faculty involvement? Also, we have no reliable way of assessing whether it works. What is called research in medical education is actually innovation based on various educational theories rather than a strong scientific enterprise. This sort of research tends to be like wandering around in the desert. • Simulated patients, or actors who imitate patients with various conditions, is superb for teaching certain skills. You can learn to take a history and physical and to communicate with patients. But it is not a useful way to learn other skills and it is quite expensive. • Lifelike models have great potential for teaching procedures and assessing response times and appropriateness. Medical schools around the country are in the process of developing such models. But they are costly and there are no standards to assess them. Developers lose interest as well as lose funding. And evidence of their efficacy is spotty, except for procedures. • Simulated cases, where a student sits in front of a computer terminal and works through a complex decision tree on treating a patient, shows some promise. But students tend not to use them and it’s not clear why. Also, they’re often composite cases, based on the way a patient ought to present. They lack the messy real-world details so critical to understanding how medicine works. These cases reduce uncertainty, but uncertainty is our business. They need to be based solidly on what we now know about cognitive science. • Simulated procedures using computers, analogous to lifelike models, are valuable for anyone who wants to get it right before performing the procedure on real-life patients. This is clearly a major advance over what we’ve done before. • Real cases are a much more effective way to teach. There are ways to do this to enhance the learning. Instead of presenting the whole case and discussing it at the very end, the patient presents at various stages and students discuss problems at each stage. They start with minimal information and try to figure out what questions need to be asked and what they learned from the answers. Everyone is involved because when one person is answering, everyone else is thinking what they would say if they were called on. This approach is similar to the clinical problem- solving cases that appeared in The New England Journal of Medicine in 1995. • The electronic medical education system is a huge interactive source of coursework and medical information. It appears to be the future of how medical students, residents and practicing physicians will learn. Students can work at their own pace and their own chosen depth. Curricular information is in a “relational” database, which means it can be added to and used independently. The system plugs into online resources, such as books, Medline and summaries of information of all kinds. The system manages information differently for students, faculty and administrators. Students can collect information on their own Web site or computer. The faculty can create content. And administrators can conduct surveys, report grades and assess learning outcomes. To build these information systems, schools are beginning to use “open-source” software, which is free software and can be modified to your own specifications. This requires computer programmers on hand. You can take information from other sources. For example, the University of Utah offers some excellent pathology slides and the University of Washington offers a laboratory library. Resources are shared by consortia of medical schools: CRIME (Computer Resources in Medical Education) in the West and COMET (Consortium on Medical Education Technology) in the East.
  12. 12. CME/SMS Presentation Summaries June 17-18, 2005 Page 12 With all this sharing, schools might someday consolidate into one single American Medical School or even one international medical school. But there are still hurdles ahead. These new systems are hard to build on the old legacy computer systems that many schools have, and protective firewalls have to be broken through for them to work. All these communal systems raise concerns about privacy and ownership rights for shared content. When slides pass from hand to hand, changing again and again, who owns them? The fair usage doctrine, in which the courts allow anyone to use limited portions of copyrighted printed text, has not been well defined in cyberspace. We shouldn’t get too smitten with all this technology. Electronic solutions can’t address some nagging problems in medical education, such as soaring tuitions, an outmoded tenure system, extraordinary pharmaceutical influence, lack of faculty role models and a hazy concept of how much students should learn. We need to redouble our efforts to foster dedicated, skilled teachers. We have to stop piling up reform proposals that are not fully acted upon. The Institute of Medicine’s 2000 “Crossing the Quality Chasm” included a section on medical education. Then, in 2001, there was IOM’s “Health Professions Education”; in 2002, Commonwealth Fund’s “Training Tomorrow’s Doctors”; in 2003, IOM’s “Academic Medical Centers”; and in 2004, the AAMC’s “Educating Doctors to Provide High Quality Care.” It’s time to stop talking and start doing. A Call to Action – Transforming Medical Education Speaker Michael M. E. Johns, MD Executive Vice President for Health Affairs and CEO, Robert W. Woodruff Health Sciences Center at Emory University Our model of medical education and training—centered in the hospital, based on staged learning and working with bio-scientific and clinical research—is almost a century old. Is it still the best model for the future? Probably not. But unfortunately, we don’t know for sure. We don’t have good metrics to assess the array of skills and qualities that are critical to excellence as a physician. We might know what we are teaching but we do not know what our students are learning. And, worse, we have known this for a long time. We have known for decades that there is no coherence or structure to the continuum of medical education, from undergraduate education, through medical school and residency to lifelong learning. Over the past century, medical education has slowly taken a back seat to research and clinical activities. This story is told in the book, “Time to Heal: Medical Education from the Turn of the Century to the Era of Managed Care,” by Kenneth M. Ludmerer, MD. With professional development and faculty rewards geared toward research and patient care, medical education and training have spent decades on automatic pilot. Important reforms, however, have swept over the first two years of most medical school, such as revision of curricula in the 1990s. Now students learn in smaller groups that are more active and better integrate basic science into clinical experience. Educators continue to worry about the educational integrity of the overall MD program and particularly the last two years. For the first two or so years, most programs simply teach to the U.S.
  13. 13. CME/SMS Presentation Summaries June 17-18, 2005 Page 13 Medical Licensing Examination, but the fourth year is “the Marco Polo year,” when students ply the spice routes looking for their fortunes in residency training. We tend to lose track of them and they miss many educational opportunities. Do we even need a fourth year? Duke dedicates one full year to research, which clearly demonstrates that one year is not really necessary, as the basic curriculum now stands. One of the greatest opportunities in medical education is to reinvent and integrate the fourth year of medical school with the first year of residency. Even less has changed in a century in graduate medical education. Residency training is often seen more as a turn of service than a time of learning. Training is removed from the purview of medical schools and the informal influences of the “hidden curriculum” take over. As new subspecialties develop, year after year of further training is tacked on to the existing specialty training program. Otolaryngology requires five or six years of training plus two to four additional years of significant research or fellowship training. That seems excessive. Most otolaryngologists do not need six to eight years in training beyond medical school. A committee of the American Board of Otolaryngology examined the otolaryngology curriculum, with an eye to restructuring training programs, examining subspecialty tracking, and basing promotion on achievement milestones rather than time served. It was a good start, but significant changes will take a while. Reforms are necessary, but only sustained and committed leadership can carry them out. Training programs vary in size, content and quality and address the service needs of the host institution. Accreditation and certification bodies seem to be frequently change-averse and concerned about their level of control. To get an idea of what needs to happen to medical education, look at what medicine will be doing in the next 20 years with genomics, proteomics, nanotechnologies, molecular imaging, biomedical engineering, transplant technology, vascular biology, robotics, and systems and computational biology. Our medical students need some of this training now. The doctors of the future will have to be able to flow in and out of various types of teams and to work with an array of new systems and technology. Collaborative care will be a necessity, not an option. We need physicians and scientists and other health professionals who have the following skills: • Knowledge and tools, such as computation, physics and mathematics, for research; • Working flexibly with various types of colleagues in non-traditional settings; and • A global perspective, because the world gets smaller every day. The shrinking and flattening of the planet is described by New York Times columnist Tom Friedman in his book, “The World is Flat: A Brief History of the 21st Century.” In the last couple of decades health status even in remote regions of the world, regarding such diseases as AIDS and SARS, can have flat-out global consequences. Simulators that provide feedback and measurement will replace cadavers and other systems for learning about anatomy and the skills and techniques of surgery. Surgery itself may largely be replaced by other forms of treatment, like interventional radiology and nanotechnologies. For example, quantum dots—nano-scale crystalline structures that can tag tumors or genetic defects—are being jointly developed by Emory and Georgia Tech. In addition to new technologies, we need new collaborative approaches to addressing and solving health problems that involve communities and global collaboration. Skills in systems analysis and outcomes measurement will be as important as the stethoscope. We need curricula in quality improvement with outcomes measures. The possibilities are endless and one can get carried away, but
  14. 14. CME/SMS Presentation Summaries June 17-18, 2005 Page 14 new visions are needed. We have to be sure that we are preparing our students and ourselves for these new frontiers. All you’ve got to do is look back over the last 30 years of your own career and see changes that you couldn't have imagined. Looking at the challenges ahead, it is striking how parochial, limited, and perhaps even limiting our educational and training curricula is. We need vast changes in the way we educate students for this new medicine and this new world. The 2002 IOM summit on medical education produced a report, "Health Professions Education—A Bridge to Quality,” that stated: “All health professionals should be educated to deliver patient-centered care as members of an interdisciplinary team emphasizing evidence-based practice, quality-improvement approaches and informatics.” A colleague remarked, “Gee, why does the IOM have to say this?” The Blue Ridge Academic Health Group, made up of leaders in academic health centers and the health profession (co-chaired by Dr. Johns) found that very few of the myriad educational reforms proposed in numerous reports over the years were ever actually adopted. The Blue Ridge Group compiled its own list of recommendations for reform: 1) Academic health centers must create a strategy for restoring education to its rightful place alongside clinical care and research. 2) Health professional schools must advance knowledge in cognitive development, styles of learning and education theory and practice. There should be a core of scholar-practitioners with expertise in learning. We need to measure objectively what we do and do real research in education. 3) We must improve support for faculty, residents and volunteer educators. We need to develop formal clinical-educator training and support programs. Mark L. Batshaw, MD, chair of pediatrics at the Washington Children’s Center, has created a model that others can emulate. 4) We must systematically review and renew our training sites to ensure that they are consistent with our goal of seeking evidence, truth and technical competence within a humanistic environment. This also means providing space and programming for team medicine and team learning. 5) Our Byzantine regulatory framework must be streamlined and rationalized, starting with the ACGME. Broad reforms are required in GME, but to be effective and meaningful, they must be coordinated with related reforms in medical school and continuing education. This will require close coordination between the LCME and ACGME and new efforts to properly reform and regulate the no-man’s land of CME. The ACGME ought to take the lead in setting the stage for educational reform. It has monitored and evaluated the quality of graduate medical education to ensure quality for many years, but one area it has not carefully evaluated is its own performance. It is time that the ACGME—perhaps the most important regulatory organization in medicine—undertake its own thorough self-assessment. The ACGME should first appoint an internal panel to review all aspects of its mission, organization, performance, outcomes and where it needs to go. Then it should invite peer review by an external blue-ribbon commission.
  15. 15. CME/SMS Presentation Summaries June 17-18, 2005 Page 15 This type of thorough review could provide an extraordinary array of evaluations and recommendations to guide the development and regulation of medical education for the century and could set a new mark. The ACGME should address calls for more flexibility, allowing for creativity in core curriculum development for all residents and reducing the number of proscriptive dictates from the residency review committees in each specialty. Focusing on education and training can seem somewhat of a distraction at a time when we face significant challenges in expanding the frontiers of science and managing in the health care marketplace. However, we are a profession precisely because society has granted us the authority to set our own standards and to largely manage our own education and training. Ours is a calling that not only includes taking care of patients but also defining what a physician is and what standards each of us should be held accountable to. We need to hold ourselves to standards of training and lifelong learning appropriate to the noblest professions in a new century of health and healing. Speaker Michael E. Whitcomb, MD Director, Institute for Improving Medical Education, Association of American Medical Colleges (AAMC) Editor-in-Chief, Academic Medicine The quality of care in this country is not at the appropriate level, and the way doctors have been educated is, to a large extent, to blame. Medical educators cannot disconnect themselves from their “product”—the medical outcomes of physicians. Educators have not done all they can to make sure physicians meet their responsibilities in an incredibly challenging environment. It makes no difference if we design the most innovative undergraduate curriculum in the world if the physicians we taught do not provide high-quality care. Quality of care is falling short. If you have a chronic condition in this country, the likelihood of receiving a standard of care that is accepted within the community is almost a coin flip, according to a paper by the RAND Group, “The Quality of Health Care Delivered to Adults in the United States,” which was published in The New England Journal of Medicine in 2003. There is a linkage between what we do as educators and what our students will do as practicing physicians. Educators should not be recreating the next generation of physicians in their own likeness. They should be educating physicians who are capable of providing high-quality care on their first day in practice. Educators need to review the formal educational structure of medical school and residency training and help practicing physicians maintain their clinical competence. In the past century, most medical education reforms have focused on medical students. But it cannot be shown that any change in the medical school curriculum has any effect on the quality of care provided by students when they eventually enter practice. That’s because researchers cannot control the rest of the educational experience students have after graduation and when they are in practice. Of course, we should continue contemplating medical school reforms because “informed intuition” and a sense of what is the right thing to do are sufficient reasons to make changes. But it’s not possible to link those changes to the quality of care being provided by physicians in practice. It can’t be done. Some very exciting changes are occurring in medical student education. Dr. Ronald Franks, Chair- Elect of the AMA Section on Medical Schools, has been studying possible reforms in an informal survey of medical schools deans on behalf of the AAMC Council of Deans. Medical students should study the development of appropriate attitudes, professional values and an understanding of the roles
  16. 16. CME/SMS Presentation Summaries June 17-18, 2005 Page 16 of physicians, according to Edmund D. Pellegrino, MD, Professor Emeritus of Medicine and Medical Ethics at Georgetown University. As members of the profession, they will have a responsibility to the society as a whole. William M. Sullivan at the Carnegie Foundation discusses this in his 2004 book, “Work and Integrity: The Crisis and Promise of Professionalism in America.” The spotlight for reforms needs to shift from medical schools to what occurs afterward. We have a major problem with the design and conduct of residency education. To a large extent, residency training is based on clinical service rather than educational needs. The inpatient environment no longer serves many of the purposes of training for practice in the community. A manuscript submitted to Academic Medicine surveyed internal medicine residents at a West Coast institution about their perceptions of the ACGME’s new 80-hour-per-week limit on duty hours. Overwhelmingly, they said it had a positive impact on their lifestyle and personal relationships, but it adversely affected their education. In redesigning the schedule to meet the limit, programs have eliminated some educational experiences. It’s time to stop talking and to do something about graduate medical education. The changes are necessary because residents are going to enter practice and contribute to the national report card on quality of care. Organizations representing internal medicine, surgery, family medicine and other disciplines have all indicated in formal reports or in conferences in recent years that residency training in their fields must be redesigned. But none of these disciplines has reached an agreement on what should be done. It is time to stop talking and take action. One of the most profound critiques of the problem comes from new graduates of training. A paper in the American Journal of Medicine this month, written by some graduates of internal medicine residency programs, underlines the gaps between what they were taught and what they had to know when they started to practice. They said they were not adequately prepared for the clinical encounters they faced. Continuing medical education is the piece of the continuum where there is the most evidence that things are broken. The disappointing measures of quality of care, mentioned earlier, reflect the behaviors of physicians already in practice. It makes sense to help change their behaviors through CME. This is not occurring now. David A. Davis, MD, Associate Dean for Continuing Education for the Faculty of Medicine at the University of Toronto, has done a number of studies looking at whether current CME experiences actually change doctors’ practice behavior and improve their clinical outcomes. The answer is “no.” There are at least four systematic reviews in the Cochrane Collection, prepared under the aegis of the Cochrane Collaborative, showing that attending lectures, listening to subjects that may not be relevant to your practice, does not contribute to improving quality of care. The stakes are big. If we can improve CME, there is the possibility of changing practice patterns of half a million physicians currently in practice. And that could have a truly dramatic impact on the quality of care delivered in this country. Reforming CME will be a challenge. The process is overseen by multiple organizations with policies that are not connected, with no ability to coordinate changes. Physicians continue to go to CME exercises that have no effect on their practices because they need to satisfy illogical requirements for state licensure. Physicians licensed in Ohio, for example, must complete a certain number of CME hours every two years, but they are not required to take those hours in their own specialties. An internist can get CME credits in obstetrics. Courses do not have to have anything whatsoever to do with the nature their practices. It might behoove pulmonologists to improve their treatment of asthma,
  17. 17. CME/SMS Presentation Summaries June 17-18, 2005 Page 17 but it’s not required that they do so through CME. We need to be socially responsible and look at CME in a logical way. Systems have to be put in place that support our educational objectives. To improve quality tomorrow, we need to change the enterprise that currently is in place today. It won’t be easy to do. The variety of organizations that are involved in regulating education, certification and licensure will have to coordinate their responses. And people have to stop protecting their own vested interests and seriously work together. We need to release the creativity of educators and build CME systems that will support physicians in practice. Our goal is nothing less than improving the quality of medical care in this country. Speaker Kenneth I. Shine, MD Executive Vice Chancellor for Health Affairs, University of Texas Health System Former President, Institute of Medicine One of the major failings in our educational system is an inability to develop leadership skills, communicate those skills and have them acted upon by physicians. All of us ought to be providing leadership in areas of change. This organization and every other physician organization needs to start behaving as role models for the changes that we want to see. For example, we want to expose our medical students to clinical problem-solving, but we don’t organize our own CME sessions that way. Physicians attending this meeting have the opportunity to have this program count toward their CME credits. They can fill out a form and get maybe five to six hours of CME credit for listening to lectures by seven white males who are supposed to be talking about how to bring about change in education. But the probability that they will go back and make major changes at their institutions, based on what they heard here, may only be slightly better than that of the average physician changing his or her own practice behavior after CME. If we want to see change, we as leaders ought to be exemplifying it. Rather than getting all your CME credit for attending a course, perhaps you should get half of the credit six months from now, after you have made innovations in education that reach the outcomes discussed here. That would show our leadership and it would be an example for practicing physicians. They would then go to a CME lecture on beta blockers, get half the credit based on attending the course, and then the other half after they demonstrate increased use of beta blockers in their practices. As educators, we always need to skate ahead of the puck. When the hockey player Wayne Gretzky was asked why he was such a fantastic success, he said: “It’s because I always skate to where the puck’s going to be.” No matter how smart and accomplished you are, you still have to skate ahead of that puck. You have to be flexible and roll with the changes. There’s a story from the early 1970s that may or may not be true. Richard Nixon, Henry Kissinger, a priest and a hippie were in an airplane over the Western United States when they ran out of gas. It turned out there were only three parachutes. Nixon immediately said: “I’m the President of the United States. I lead the most powerful country in the free world. I deserve a parachute.” The other three agreed. Kissinger said: “Well I’m Secretary of State. I’m one of the most important intellects in Western Civilization. I deserve one, too. The other two agreed. The priest turned to the hippie and said: “Son, I’m 78 years old. I have no family. I’ve made my peace with God. I want you to have the
  18. 18. CME/SMS Presentation Summaries June 17-18, 2005 Page 18 last parachute.” The hippie looked at him, smiled and said: “Not to worry, the smartest man in the world just jumped out of this plane wearing my backpack.” U.S. health care is a non-system. Dr. Walter McDonald, in his speech yesterday, referred to it as a “mom-and-pop operation.” It’s a cottage industry, despite the fact that the cottages are huge and have very sophisticated technology. Over the next 10 to 15 years, it will, in fact, evolve into a system of health care. It will have to become more organized and centralized because of the need to make large capital expenditures and to develop interlinking information technology. Physicians will have to link with each other because they can’t afford to continue to be solo. Rising health care costs are going to be an increasing influence on the system in the foreseeable future. One problem with the doctor- patient relationship, as presented by the AMA, is that it does not take the cost-effectiveness of the interaction into account. We’re going to have to seriously deal with that aspect of the patient-doctor relationship. Major changes are swirling all around us. Explosions in health care knowledge and technology will profoundly affect the delivery of health care. Health disparities are now driving health care in this country. Close to 80% of health care expenditures are related to chronic illness, and this seems only to be getting worse. Lack of insurance is rising among individuals where health disparities are the greatest. Meanwhile, consumerism will be a major force in health care in the next decade or two. This trend is partly driven by access to the Internet, which is basically access to information. The purchasers of health care are going to be demanding more and more. Recently, the Centers for Medicare and Medicaid Services were giving essentially a consumerist argument in favor of informed consent for surgery. CMS was reflecting patients’ views, the consumer’s views. The consumerist view will impact other activities, such as the use of “ghost surgeons” to stand in for the surgeon who was expected to carry out the procedure. Should patients be informed about this change? Consumers are going to be demanding to know what is happening. Being able to adapt to all the changes we are seeing will depend on systems operations. Donald M. Berwick, MD, president of the Institute for Healthcare Improvement, argues that health care must be based on “microsystems”—care teams made up of the physician in the office, his secretary, his nurse, the pharmacist, the patient and the family. Health care has become much more complicated for there to be just one physician giving care. Eli Ginzberg, PhD, the late health care economist at Columbia University, used to recall that in the 1920s there were three health care providers for every one physician in the United States. Today, there are 16 providers for every one physician. Health care is a very big, complex operation that requires teamwork. Dr. Elliot Sussman emphasized this in his speech yesterday. He also talked about the importance of data-collection and analysis in order to focus on outcomes and effectiveness. What skills do physicians need in order to deal with these new challenges? First, they need the ability to lead, whether they are students, residents or in practice. They also need communications skills and to be able to access and handle information. And they have to solve problems—whether those have to do with patient safety, diagnosis, therapy or whatever. This brief list of skills is fundamentally important to making the health care system work. As the changes swirl around us, we ought to reconsider what we mean by professionalism. In the 20th century, the essential elements of the profession’s paradigm were altruism, self-policing and a body of knowledge. We still want students committed to altruism. Self-policing is still necessary, but we have done an abysmal job with it. As a result, the profession is seeing increasing intrusion from
  19. 19. CME/SMS Presentation Summaries June 17-18, 2005 Page 19 government and others. But the situation has changed most dramatically in the area of knowledge. We used to be proud as a profession of adding to the body of medical knowledge. Only we, the “shamans,” had certain knowledge. We would convey it to patients but only we held it. Now, because of the Internet, our patients are often aware of what is going on before we are. They have access to clinical trials. They know about differential diagnosis. They learn about things very quickly. Back in the last century, the physician was proud of his or her own autonomy. Managed care really frightened physicians because it was about loss of autonomy. A large number of physicians were in solo practice. It’s hard to appreciate that fact from the vantage point of academic health centers, where there are large group practices, but right up until the end of the 20th century, one-third of U.S. doctors were in solo practice and another 20% to 30% were in small practices. That’s beginning to change. The paradigm for the 21st century stresses teamwork. And when you have a team, leadership becomes important. But it’s something that has to be learned. Being the person who can write the prescription or admit the patient does not teach you how to be a leader. It doesn’t show you how to motivate people or how to get everyone working together—whether it’s in your office, in the hospital or elsewhere. The new paradigm of leadership means that the physician takes responsibility for how the team functions and how the outcomes turn out. We talk a lot about the need for multi-professional education—with doctors, nurses and others—but at some CME activities it’s hard to find the other professions. We need to create interactions between the professions. A number of the University of Texas campuses that have multiple professional schools provide a series of inter-professional experiences, from seminars to actual clinical work. Students in nursing, medicine, dentistry and public health are learning together. That’s good because they need to get acculturated. They need to understand the expectations of each other. They need to work as a team. In the new paradigm, just teaching medical skills will not be enough. That’s because physicians’ own clinical performance will not be the ultimate determinant of the quality of the care they give. Rather, it will be how well the system works and how well the team works for them. Solo practice is giving way to systems of care. Texas still has a very large number of solo practices, but these doctors can’t afford information systems to learn about effectiveness. To stay in the game, independent practices—in family medicine, in particular—are banding together to develop virtual systems that share information technology and outcomes data. So you can see that one outcome of the electronic health record is practice consolidation. The electronic health record is coming even to small towns. Brenham, Texas, population 15,000, is famous for making Blue Bell ice cream. A family medicine practice there developed a very sophisticated electronic medical record because they needed to recruit two young family physicians. These younger doctors had been using it in training and decided they couldn’t go into practice without it. In fact, the University of Texas Health System is switching over to electronic health records. It will be a marketing tool. The university will be able to offer you and your doctor the ability to access your health records at any UT institution. Last century, we were committed to continuous learning in education. Continuous learning is great, but it doesn’t necessarily mean continuous improvement. Faculty at medical schools are devoted to the discovery of new knowledge. They do not understand nor accept the notion that they have to continually improve the educational product and the health care delivery product. The 21st century
  20. 20. CME/SMS Presentation Summaries June 17-18, 2005 Page 20 physician has to accept as part of his or her professional responsibility the continuous improvement of his or her practice, operations and outcomes. That means understanding data, outcomes and problem- solving. Learning also has involved the blame-shame paradigm. When a mistake was found on rounds, it was important to know who did it, whose responsibility it was, and who was to blame. That attitude encouraged tort actions; the legal profession also wanted to fix blame. But in the 21st century, learning cannot continue to be “blame and shame.” A number of academic centers—though far fewer than there should be—have embraced patient safety as a system. Their students and residents are included in understanding medication errors. They are not necessarily doing root-cause analysis for the worst cases but they are talking about near misses. Our paradigm has to change. Knowledge for its own sake is not an adequate outcome. One has to be committed to changing as physicians, teachers and students. We are going to have to confront a rather different paradigm. If we don’t adopt it ourselves, it’s likely to be imposed in a variety of ways. The educational experience will have to include an understanding of systems. This has to do with the way you teach about individual cases and undertake mortality and morbidity conferences. To what extent are you including systems analysis and evidence-based analysis in everything you do? The curriculum needs to include elements such as multidisciplinary acculturation, problem-solving, approaches to safety and quality-improvement methodologies. Decision-making is very important. We take it for granted that we known how to do it—that smart people will learn this very quickly, as long as they have the data. In fact, it’s a far more complex issue. As Dr. Michael Johns pointed out, we have got to recover the fourth year. We have got to significantly limit the number of audition rotations. For this to work, academic institutions need to convince affiliated subspecialty programs to drop their insistence that candidates have an audition. A clear and explicit limitation, which has been carried out at a number of schools, is important. The fourth year could be an opportunity to introduce multiple tracks and multiple degree pathways and to create an important series of “selectives.” There would be a list of selectives in various topics, such as ethics. The fourth-year student would be required to pick at least one selective. It’s all very well to have had studied the broad principles of ethics as course work in the first or second year, before clinical training in the third or fourth year. But then it’s important to revisit ethics after gaining some clinical experience. The ethical issues come alive after you’ve had enough experience to really feel and know some of the complexities of making those ethical decisions. There could also be selectives in management, quality or problem-solving. Fourth-year students could study a series of case-analyses, based on the experience that they had during their clerkships. They could study technology-transfer, in order to understand how products are developed or how the pharmaceutical industry works. They need to understand the environment in which they are working. They need to understand intellectual property. A selective would last two to four weeks. A selective could take fourth-year students back to basics, such as relating the basic science they learned as undergraduates to clinical science. Or they could study rural health. The University of California-Los Angeles developed a doctoring course that began
  21. 21. CME/SMS Presentation Summaries June 17-18, 2005 Page 21 with the first day of medical school. It was the brainchild of Michael Wilkes, MD, PhD, now Vice Dean for Medical Education at University of California-Davis. The course culminated in the fourth year around synthesizing the role of the doctor. It included practice and some organizational issues. What else should be in the curriculum? Medical students are very worried about how they will adapt to medical practice. Some educators argue against teaching practice issues, saying that reimbursement and other aspects of practice will change. But the same argument could be made not to study molecular biology. Part of a doctoring course could teach the essentials of practice so that students understand some basic principles. There may also be some opportunities to understand and participate in clinical research. Many institutions are adopting various parts of these proposed changes. But this is not just about putting more topics in the first, second or the third year. Rather, it’s about teaching the first, second and third year in a slightly different way, and then recapturing the fourth year. One example of teaching in a different way is shifting from teaching in the hospital to outpatient settings. Health care is shifting to the ambulatory arena. In many academic institutions, 60% of surgery may already be ambulatory, but the teaching does not reflect that. Nine years ago, Gerald T. Perkoff, MD, Curators Professor Emeritus at Washington University School of Medicine, wrote an article for The New England Journal of Medicine on the need for education in the ambulatory environment, but efforts to make that happen still whistling in the wind. Things may change slowly, but, like Don Quixote and his tilting at windmills, it is our job as educators to keep trying. We do see progress in some areas. In 1971, the first published research on length of stay after myocardial infarction found that long stays caused locked shoulders, pulmonary emboli and other health problems. But by 1995, when the Institute of Medicine began its quality initiative, the medical community was very receptive to these kinds of studies. That took 25 years, which is still a long time. But it took less time for the electronic health record to catch on. The IOM started issuing reports on the electronic health record in the late 1980s. Sixteen years later, President George W. Bush said every physician should have one. If we can go from a 25-year to a 16-year response time for new ideas in health care, maybe we can make some significant changes in medical education in the next five to six years. Even if it turns out to take longer than that, we—like Don Quixote—should regard it as a battle worth fighting. Not knowing exactly how things are going to change is not an adequate excuse for failing to do what we think is right under the circumstances. Speaker Emmanuel G. Cassimatis, MD Immediate Past Chair, Council on Medical Education Chairman, Accreditation Council for Graduate Medical Education (ACGME) The AMA’s Initiative to Transform Medical Education (ITME) will address the challenges identified by those who spoke yesterday and today. The Initiative has roots going back five or six years. It is a comprehensive effort, directed at medical education reform across the continuum of education and training. It is intended to meet the needs of patients and the public.
  22. 22. CME/SMS Presentation Summaries June 17-18, 2005 Page 22 Some 15 or more reports during the past 10 years provide useful background on gaps in medical education, but more broad-based data-gathering is needed. The Initiative plans to complete data- gathering and propose some operational approaches rather quickly. A 2002 report by the Council on Medical Education mapped out steps the process should take: • plans are developed for a comprehensive Initiative to address the interface of education and the health care delivery. • an internal working group identifies a comprehensive set of issues to be addressed. • a broad-based educational initiative will obtain consensus on the issues, develop recommendations to stakeholders and develop and disseminate plans for implementation. The Initiative is a convergence of previous medical education and medical ethics initiatives: • The Blue Sky Group, a subcommittee of the Council on Medical Education, reviewed previous reports and formulated recommendations for a comprehensive medical education reform initiative. This may require a complete redesign of the continuum of medical education. Some specific concerns have come to light, such as the difficulty of changing career paths in midstream. • In 2003, the AMA Ethics Standards area developed Strategies for Teaching and Evaluating Professionalism (STEP), a partnership with 10 U.S. and Canadian medical schools to create new methods for teaching professionalism and evaluating the success of those methods. Each school received $15,000 in seed money for the program’s three-year period. The principal investigators for STEP presented the final results of their project in May of 2005. The Leadership Group, which oversees ITME, is made up of one Trustee (Peter W. Carmel, MD) and the Speaker of the House (Nancy H. Nielsen, MD, PhD); two members of the Council (Carl A. Sirio, MD, and Dr. Cassimatis); representatives from the Medical Students Section (Michael G. Katz), the Resident and Fellow Section (Kelly Caverzagie, MD) and the Section on Medical Schools (Dr. Jobe). It has extensive staff input from Modena H. Wilson, MD, MPH, AMA Senior Vice President for Professional Standards, and from senior staff in the Medical Education and Medical Ethics groups. They include Audiey Kao, MD, PhD, Vice President for Ethics Standards; Barbara S. Schneidman, MD, MPH, Vice President for Medical Education; Barbara Barzansky, PhD, Secretary of the Council on Medical Education; and Paul H. Rockey, MD, MPH, Director of the Division of Graduate Medical Education. When the Leadership Group met on May 3, members agreed that medical education cannot be considered in isolation and that values such as professionalism clearly shape medical education. Everyone agreed that we need to strongly affirm medicine as a calling. This fall or early winter, the Leadership Group will convene a broad-based group of stakeholders to collect proposed changes in medical education as they relate to the health system. This meeting will include distinguished educators and representatives of the public and the health care system. The intention is to hear from people with different views who may well disagree with some of the Group’s perceptions. Data-gathering will focus on: • the health care delivery system, especially safety and quality; • organization and financing of medical education; • affirming and instilling professional attitudes and values;
  23. 23. CME/SMS Presentation Summaries June 17-18, 2005 Page 23 • the curriculum, including content and formal sites for training; • the reintegration of public health; and • the role of professional regulation in bringing about change. The public health function has been split off from the medical school at many institutions, but this never happened at the medical school for the military, the F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences. The school sees public health as an integral part of the education of physicians. Its Department of Preventive Medicine and Biometrics is larger than most schools of public health. Once the information on possible reforms is collected, the Leadership Group will review it, based on prioritized recommendations from the stakeholder groups, then develop a broad-based consensus on recommendations for change and create focused implementation strategies. The Group will then carry out pilot programs. Because of the broad support it is getting from the entire AMA, the Board of Trustees and Executive Vice President, the Leadership Group is well positioned to meet these ambitious goals. Question and Answer Session Comments David E. Swee, MD Professor of Family Medicine, UMDNJ-Robert Wood Johnson Medical School (Piscataway) Certain kinds of practitioners have higher quality outcomes, according to research by Barbara Starfield, MD, MPH, a professor at Johns Hopkins Bloomberg School of Public Health and Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation at the Center for Health Studies in Seattle. Donald M. Berwick, MD, at the Institute for Healthcare Improvement, is a good source for micro-systems. Certain reforms are needed. Rather than deliver more and more knowledge about diabetes, for example, CME should focus on how to deliver better diabetes care. Educators need to focus on the ultimate product—the quality of care of doctors in practice. Academic health centers may be a potential avenue of reforms, but they also cause the problem. They should be adopting new models of health care that can raise U.S. quality of care to levels in France and Germany. Dr. Michael Whitcomb: The way we educate doctors and the environment in which they are educated ultimately contribute to the quality of health care. At the AAMC, David P. Stevens, MD, who will be speaking later, is responsible for proposing new systems within academic health centers. Dr. Kenneth Shine: The values that students take with them out of medical school are important. Some faculty members still think their individual genius is what matters in medical education, but a more important element of the learning are values, orientation and principles. Medicare authorities are being asked to alter regulations so that residents can receive more training in ambulatory settings. Question Carol Aschenbrenner, MD Vice President for the Division of Medical School Standards and Assessment, AAMC Co-Secretary, Liaison Committee on Medical Education (LCME)
  24. 24. CME/SMS Presentation Summaries June 17-18, 2005 Page 24 You can alter the teaching, but your success also depends on the characteristics of the learner. Some people are early adopters, some adopt later and others adopt latest. How does the selection of medical students and residents affect education? Dr. Michael Whitcomb: We still don’t really know what applicants would make the best doctors, but Ed Pellegrino, the medical ethics professor at Georgetown, said they should be people who are “thoroughly honest.” Dr. Michael Johns: The concept of early, later and latest adopters is part of the diffusion theory developed by the late Everett Rogers, author of the book, “Diffusion of Innovations.” We need several types of learners. The innovators test the alpha and fail on a regular basis. Early adopters are opinion leaders but they don’t want to be the first out of the box. Then there are the laggards, whom we don’t really want. The bottom line, we need people with integrity who really care about providing quality of care. Dr. Kenneth Shine: Sherman M. Mellinkoff, MD, the late Dean of the University of California-Los Angeles School of Medicine, would always ask whether a job candidate was honest, which was irritating for hiring faculty to hear, but it was an absolutely crucial question. However, rather than worry about the caliber of medical school applicants, we should be focusing on trying to improve the environment they learn in. Question Peter J. Fabri, MD Member-at-Large, Section on Medical Schools Associate Dean for Graduate Medical Education at the University of South Florida College of Medicine The problem with medical education is the faculty. They tend to stifle creativity. Why don’t we define the competencies of faculty and hold them to it? Dr. Michael Whitcomb: In his book, “Work and Integrity,” Bill Sullivan says academic culture has created individuals who don’t reflect the needs of the profession. One problem is that teaching is often not the way faculty members are promoted. Faculty have the wrong incentives. Also, faculty members don’t spend enough time with the same students and residents. For instance, students and residents complain that the new two-week attending block for Internal medicine faculty is not enough time to get to know them. Dr. Michael Johns: Institutional leaders need to set the standards and put them into the appointment and promotion requirements. Emory University has done this. The idea of defining specific competencies is a good one. Johns Hopkins has a formal curriculum for educating clinical investigators and in public health that leads to a master’s degree. The program has been widely adopted around the country. This sort of formal training could be done with some of our faculty in education. A lot of schools have “teaching teachers to teach” programs. Dr. Jerome Kassirer: Last year, Harvard Medical School started a three-day course in leadership for faculty (called Leaders in Health Care Education). The course does not just help people to learn leadership skills but also helps them to influence the behavior of colleagues. It needs substantial numbers of participants throughout the institution to be effective.
  25. 25. CME/SMS Presentation Summaries June 17-18, 2005 Page 25 Dr. Emmanuel Cassimatis: Teaching is not a science, where you can simply show people how to do things. A lot of human issues are involved. But it is important to create a culture where teaching is valued and where good teachers share thoughts and ideas. Four years ago, the ACGME established the Parker Palmer “Courage to Teach” Award, and since then it has been given to 41 teachers. Now the ACGME is about to start a “Courage to Lead” Award to recognize designated institution officials, the officials who oversee training programs at a particular institution. The Parker Palmer awardees are now like a brotherhood. They have been inducted into the Arnold P. Gold Foundation (which advances humanism in medicine), and have been invited to a retreat at the Fetzer Institute (a retreat that fosters integration of one’s inner life with one’s outer life of action in the world). Comments Paul A. Pipia, MD Assistant Professor and Division Chief for Physical Medicine and Rehabilitation, SUNY Downstate Medical Center College of Medicine New York State is a good place to see how the ACGME’s new 80-hour limit on residents’ duty hours effect programs. Similar rules have been in effect in New York since 1989. What has happened is that New York resident physicians have learned to play the system for their own benefit. The most popular day to be on call is Thursday, because if you can get Friday off, you can have a long weekend. The duty limits and other new ACGME requirements are unfunded mandates. Somebody has to pay for them. The speakers talk about leadership by example, but the leaders don’t have to follow the rules they make. Most of the ABMS board members who approved its new Maintenance of Certification program are exempt from it. Look at the message we send to our medical students and residents. Comments Larry A. Rues, MD At-Large Member, Section on Medical Schools Member, Gropper Family Care Center, Kansas City, Mo. The problem with faculty goes deeper than not getting rewarded for good teaching. The best clinicians do not get the respect they deserve. Students who learn from community physicians can experience how doctors form relationships with patients and take responsibility for care. But in the academic medical center, patients come and go, there are too many people involved in a case and there is “a collusion of anonymity,” to paraphrase the British psychiatrist Michael Balint, author of the 1964 book, “The Doctor, His Patient and the Illness.” We need to go back to the pre-Flexner days, when students learned from physicians in everyday practice. Dr. Kenneth Shine: Physicians in the academic medical center can, in fact, develop relationships with patients. There are models that work very well there, although they are not necessarily as continuous as in a community practice. Using community practices for teaching can be a challenge because the practitioner is under enormous time and economic pressures. The University of Texas system, however, uses community practices very extensively for teaching. It’s a very useful experience for students. Comment Gary M. Gaddis, MD, PhD Associate Professor of Emergency Medicine, University of Missouri School of Medicine-Kansas City
  26. 26. CME/SMS Presentation Summaries June 17-18, 2005 Page 26 Switching specialties happens all the time. An emergency physician may gravitate into occupational medicine. A cardiologist who can’t wear a lead apron because he is disabled with back pain needs to retrain. A surgeon develops a tremor and can no longer operate. But physicians who want to move to another specialty have to go through a complete residency all over again. There has got to be a better way to let them re-educate themselves and be useful to society. Dr. Emmanuel Cassimatis: Military training programs already allow this. For example, physicians who are going blind can go on a faster track into psychiatry. It’s an issue that ITME plans to address. Comment and Question David C. Leach, MD Executive Director, Accreditation Council for Graduate Medical Education (ACGME) In answer to the speakers’ calls that the ACGME undertake extensive reforms, the Council has already undertaken an extensive self-study and is expected to adopt a new Mission Statement next weekend. The ACGME is shifting from profession-regulated oversight to patient-centered oversight, linking graduate medical education to improving medical care. It is conducting pilots at 70 internal medicine programs. In exchange for annual outcomes data, the ACGME is waiving 40% of their program requirements and has extended their accreditation cycle to 10 years. As the ACGME shifts focus to assessing the competence of sponsoring institutions, what should it be looking for in the institution? Quality of patient care? Transparency of data? Disclosure policies? Or anything else? Comments Harry A. Gallis, MD President, Alliance for Continuing Medical Education (ACCME) Former At-Large Member of the Section on Medical Schools People incorrectly assume that CME is ineffective and not changing in any important way. The field is, in fact, changing, but it is difficult work. In medical school and residency training, you have the luxury of dealing with small select group of learners. At a CME-granting county medical society, by comparison, a thousand or more physician-members may be seeking CME credit. These physicians usually do not discuss the types of CME they received with society officials and their other sources of CME, such as from their specialty societies, are not always clear. We have a major systemic problem in the 40-year continuum of continuing medical education. We need to help the profession understand better what CME ought to be providing them. There are some promising signs of change. A group of physicians in Charlotte asked for help to transform their practice to improve clinical outcomes. This is where we want to go with CME as a profession. To make this work, we need to build a partnership between “you and me, GME and CME.” Dr. Kenneth Shine: Physicians look for the least common denominator to fulfill state CME requirements. They choose cookie-cutter kinds of activities, for the most part. Creating a learner- driven process is the way to go. The usual CME lecture format is probably not the best way to help those physicians in Charlotte improve their clinical outcomes. There are other ways to do it, such as problem-solving. Dr. Emmanuel Cassimatis: Some of the issues with CME are too difficult for any one group to resolve, which is why the AMA Initiative is bringing together everyone involved in the process. The ACCME has done a tremendous amount of work and it has met twice with the Council on Medical
  27. 27. CME/SMS Presentation Summaries June 17-18, 2005 Page 27 Education to share ideas. The Council on Medical Specialty Societies has created a Task Force on Repositioning CME (whose work led to the new Conjoint Committee on CME, which represents 14 stakeholders in CME, including the AMA and ACCME). Bruce E. Spivey, MD, Deputy Executive Vice President of CMSS helped lead this effort. Effective Strategies for Improvement in Clinical Care Systems Speaker David P. Stevens, MD Director, AAMC Institute for Improving Clinical Care The Institute for Improving Clinical Care is about better, safer care in academic settings. Its goal is to make sure medical students learn in clinical settings that “reflect the best in achievable patient care.” That is important for patients. It is good for faculty members, who are time constrained by commitments to both clinical care and education. And it helps residents and students. But before we introduce changes for students, we need to embrace them for ourselves. That is what Gandhi did and it is a worthy goal for medical educators, too. Also, the people in charge—whether they are physicians or pilots—need to draw from the expertise of those they oversee. This is one of the lessons learned from the crash of Air Florida Flight 90 in 1982, in which 90 people died. The pilot ignored the first officer’s concern that conditions were too dangerous for takeoff. The crash prompted the air transport enterprise to overhaul airline safety procedures and training. Flight simulators now teach pilots how to deal with decision-making under stress. Medicine has also had its share of headline-grabbing deaths due to breakdowns in decision-making and it, too, is attempting to improve decision-making processes. After the 18 month-old infant Josie King died in 2001 due to mistakes, Johns Hopkins Hospital started the Josie King Foundation, which has as its goal the reduction of medical errors. A number of experts have come up with methods for ensuring quality. Karl E. Weick, PhD, Professor of Organizational Behavior and Psychology at the University of Michigan Business School, has taught us a lot about “high-performance, high reliability organizations.” These organizations have a preoccupation with failure. They tend to focus on what might go wrong. They dissect the situation to get to the underlying problem. Eugene C. Nelson, DSc, MPH, Director of Quality Education, Measurement and Research at Dartmouth-Hitchcock Medical Center, has dissected high-performance clinical microsystems. At its smallest level, a microsystem is made up of a doctor, nurse, support staff and patient—each doing what he or she does best. Don Berwick, MD, president of the Institute for Healthcare Improvement, says reduction of clinical errors also involves “vitality,” which means being able to keep on top of everything that could go wrong. We need to build flexible authority structures because we live in an era of rapid change that will move even faster tomorrow. As the Air Florida crash demonstrated, the most important person at any given moment in a high-risk organization ought to be the person with the most valuable information, regardless of rank. In this sort of system, the typical authority gradient of faculty, resident and student is turned on its head. In new topics such as genetics or information technology, students may be more knowledgeable than faculty. We’re all learners when we talk about improvement and safety.
  28. 28. CME/SMS Presentation Summaries June 17-18, 2005 Page 28 People who run systems have to deal with three kinds of problems: simple, complicated and complex, according to Brenda Zimmerman, PhD, Associate Professor of Strategic Management at the Schulich School of Business at York University in Toronto, and Sholom Glouberman, PhD, Adjunct Professor at McGill University and the University of Toronto. A simple problem is like a recipe—you do it the same way each time. A moon rocket is a complicated problem—many decisions are made, but you do them the same way each time. Health care is complex—you may follow some formulas, but the result doesn’t turn out the same every time. You’re not supposed to use a complicated solution to solve a complex problem. An example of a complex problem requiring a complex solution is Brazil’s fight against HIV-AIDS. A huge billboard campaign urging people to use condoms and take other measures hadn’t slowed the pace of infection down. So Brazil went to the World Bank and asked for a waiver from patent laws so that it could manufacture a new HIV-AIDS drug. The World Bank can grant waivers for natural disasters, and Brazil argued that the AIDS epidemic was a natural disaster. It got the waiver, distributed the drug, and AIDS patients began living longer. What is the role of learners in complex health care environments? Are they just drive-by observers or are they real owners of the care? The Wagner Chronic Care Model, developed by Ed Wagner, MD, MPH, Director of the MacColl Institute for Healthcare Innovation at the Center for Health Studies in Seattle, has been implemented in hundreds of clinical settings but not in many academic institutions. It involves patient self-management, such as checking your own blood pressure and weight and then making changes in your regimen. If your weight goes up five pounds, you increase your diarrhetic. This care is systematic, inter-professional work—asking questions like, what percentage of patients have Hemoglobin A1c levels below 7%? It can be in the form of group visits or e-mail, which are still not usually reimbursed. The Academic Chronic Care Collaborative, which the AAMC just started, works with 35 teams at 22 member hospitals of the AAMC’s Council of Teaching Hospitals. The collaborative has a set duration, a national faculty, and is supported by the Robert Wood Johnson Foundation. Participants need the commitments of their leadership, the resources to carry out their work and cooperation from chairs and program directors. Doctors, nurses, residents and program directors work together. Nursing leaders play a key role. The first two-day learning session will take place two weeks from now. This collaborative is based on the Breakthrough Series Collaborative, developed by the Institute for Healthcare Improvement, which speeds up the improvement process. Each institution must alter the basic model before it can work. Teams go back to their institutions to make a series of improvements, and then meet again four months and eight months later to discuss problems and exchange solutions. About 70% or 80% of them will successfully make the transformation. Once their systems are up and running, participants need to convince employers and insurers to pay for them. One big change in the inpatient model is development of the rapid response team, which is called in to treat hospital patients in emergencies when certain clear and simple indications occur. The team may include a critical care physician, a critical care nurse and a respiratory therapist. It has changed the culture in hospitals where it has been used. Usually when things go sour, the nurse or nurse’s aide calls the first-year resident, and the first-year resident looks for the second-year resident or the attending, and so on. But with these new teams, the front-line nurse has access to the best brains in the hospital. Early outcomes for these teams are in the 30th percentile range and will probably end up somewhere between 10% and 25%. When the patient codes, everyone’s goal is to find the right people to get into the patient’s room to figure out how to save the patient—and, in the process, teach medical students and residents some
  29. 29. CME/SMS Presentation Summaries June 17-18, 2005 Page 29 valuable lessons. Peter M. Senge, PhD, a Senior Lecturer at the Massachusetts Institute of Technology, talks about “learning communities” or “learning collaboratives” in his 1990 book, “The Fifth Discipline: The Art & Practice of the Learning Organization.” Rigorous scholarship on quality improvement work and safety is beginning to accumulate and professors are being promoted on work in this area. It’s time to lay down the broad professional competencies for these fields. Meanwhile, the AAMC Institute for Improving Clinical Care is trading ideas on change strategies with Gordon Moore, MD, PhD, Director of the Partnerships for Quality Education, a group that helps develop new models for training clinicians in skills and competencies for managing care in Boston. There is also the IHI’s two-year-old Teaching Improvement in Medical Schools Collaborative at 15 settings that self-fund. As Gandhi taught, the faculty have to become the change we want to create. There are strategies out there that are waiting to be harvested.