Transcript Medical Education at the Crossroads

The Role of Education in
Systems of Care
10th Annual Forum on Health Care Effectiveness
Baton Rouge, LA
January 16, 2007
Malcolm Cox, M.D.
Chief Academic Affiliations Officer
Veterans Health Administration
Carl W. Walter Distinguished Professor of Medicine
Harvard Medical School
If you don’t know
where you’re going,
any road
will get you there.
Victor R. Fuchs
Fuchs VR. What Every Philosopher Should Know About Health Economics.
Proceedings of the American Philosophical Society, Volume 140, No. 2, June 1996.
Health Care Quality
Health care is plagued today by a serious
quality gap. The current health care
system is not robust enough to apply
medical knowledge and technology
consistently in ways that are safe,
effective, patient- centered, timely,
efficient and equitable.
Institute of Medicine. Crossing the Quality Chasm:
A New Health Care System for the 21st Century (2001).
Dimensions of a High Performance
Health System
Long, Healthy,
Productive Lives
69
71
Quality
67
Access
51
Efficiency
71
Equity
OVERALL
SCORE
66
0
100
Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
7
Quality Improvement
Action Levels
• Health care system as a whole
– Health policy formulation
• Institutions and systems of care
– Systems redesign
• Practice patterns of individual providers
– Evidence-based medical practice
Quality Improvement
Prerequisites
• Emphasize health not disease
• Convert quality into value
• Translate science into improved health
Emphasize Health not Disease
Tertiary
Care
Hospital Care
Primary Care
Increasing
Resources
Community Care
Self Care
Health Maintenance
Adapted from the Third Report of the Pew Health Professions Commission.
Critical Challenges: Revitalizing the Health Professions for the Twenty-First Century (1995).
Convert Quality into Value
Cost
Containment
Access
Quality
Adapted from Kissick WL. Medicine’s Dilemmas: Infinite Needs Versus Finite Resources.
Yale Univ Press, 1994
Translate Science into
Improved Health
Basic Biomedical Research
Translational
Research
Clinical Science and Knowledge
Medical
Education
Improved Health
Clinical Decision Making
BASIC
SCIENCE
PATHO
PHYSIOLOGY
OUTCOMES
RESEARCH
RESOURCE
ALLOCATION
CLINICAL
DECISION
Clinical Decision Making
BASIC
SCIENCE
PATHO
PHYSIOLOGY
OUTCOMES
RESEARCH
RESOURCE
ALLOCATION
CLINICAL
DECISION
Patient-Centered Care
Essential Elements
• Timely access to care
• Open and clear communication
• Coordination of care
High Performance Health System
Quality Dimensions
Getting the right
care
71
Coordinated care
70
Safe care
69
Patient-centered,
timely care
72
OVERALL
SCORE
71
0
100
Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
16
Waiting Times in Six Countries, 2005
Last time you were sick or needed medical attention,
how quickly could you get an appointment to see a doctor?
Percent of adults
100
Next day
6 days or more
Same day
23
13
17
50
16
36
17
58
56
49
13
23
45
30
13
23
10
15
3
0
NZ
GER
AUS
UK
US
CAN
NZ
GER
AUS
UK
US
Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006
CAN
17
Primary Care Performance
Quality of Physician-Patient Interaction
Quality
Elements
1998 2000
∆ (CI)
P
Communication
80.3
77.3
-3.0 (-3.7 to -2.3) <0.001
Interpersonal
Treatment
75.8
73.5
-2.3 (-3.2 to -1.6) <0.001
Physical Exam
Thoroughness
76.6
74.0
-2.6 (-3.5 to -1.7) <0.001
Trust
79.8
80.5
0.7 (-0.07 to 1.5)
NS
Knowledge of
Patient
68.9
71.4
2.5 (1.6 to 3.3)
<0.001
Montgomery JE et al. Primary care experiences of Medicare beneficiaries, 1998-2000.
J Gen Intern Med 2004; 19:991-8
Continuity of Care
• Continuity has been shown to enhance
patient and clinician satisfaction, the
delivery of preventive care and the
management of chronic disease
• Continuity provides an environment in
which the utilization of services can be
best matched with patients’ needs and
expectations
Advanced Clinic Access
• Goal: same day appointments
• Core Components
– Balancing supply and demand
– Reducing backlog
– Reducing the variety of appointment types
– Developing contingency plans
– Working to adjust demand profiles
– Increasing availability of bottleneck resources
Murray M, Berwick DM. Advanced access: reducing waiting and delays in primary care.
JAMA 2003; 289:1035-40.
Veterans Health Administration
• World’s largest integrated health care system
– 156 Hospitals, 876 OPCs, 136 NHCUs
– 7.8 million enrollees
– 4.9 million patients treated annually
• 44 million outpatient visits
• 423,000 admissions, 3.5 million BDOC
– 197,000 full-time employees
– 92,000 health professional trainees
• Acclaimed as a leader in system redesign,
quality improvement and patient safety
VA Clinical Workload
Unique Patients and
Inpatient Episodes
(millions)
Outpatient Visits
(millions)
90
5
Millions of Unique Patients and
Inpatient Episodes
80
4
70
Unique Patients
60
50
3
40
2
30
Inpatient Episodes
20
1
10
0
0
1994
1996
1998
2000
2002
2004
2006
FY 2006 and FY 2007 are projections
Implementation of ACA in VA
Staff
Clinics
Teaching
Clinics
Open Scheduling and Recalls
49%
17%
Leave Coverage
55%
29%
Planning for Contingencies
51%
29%
Prediction of Patient Needs
50%
29%
Optimizing Patient Involvement
60%
31%
Optimizing Team Care
60%
33%
59±12%
32±9%
Selected Components
Mean±SD Implementation (n=19)
Chang BK et al. Resident education in ambulatory settings:
advanced access in VA physician resident continuity clinics. Fed Prac (in press, 2007).
Resident Participation in ACA
Barriers to Implementation
• Regulatory Issues
– Insufficient continuity clinic requirement
– Duty hour restrictions
• Organizational Issues
– Rotational structure
– Curriculum governance
• Cultural Issues
– Conflict with inpatient responsibilities
– Perceptions of relevance
Ambulatory Care Models
Rotational Structure
SEQUENTIAL
BLOCK
AMBULATORY
SEQUENTIAL
LONGITUDINAL
AMBULATORY
SEQUENTIAL
RECURRING
AMBULATORY
Hirsh DA, Ogur B, Thibault GE, Cox M. New Models of Clinical Education: “Continuity”
as an Organizing Principle for Clinical Clerkships. New Engl J Med (in press, 2007)
Cambridge Integrated Clerkship
A fundamental restructuring of clinical
education, integrating all the “traditional”
clerkships into one year-long clerkship,
focused on longitudinal patient care, close
mentoring, and collaborative learning in
accordance with adult educational theory.
Ogur B, Hirsch DA, Krupat E, Bor D. The Harvard Medical School- Cambridge integrated clerkship:
A pilot, multidisciplinary, longitudinal, integrated clerkship. Acad Med (in press, 2007).
Clinical Clerkships
Integrated Model
SEQUENTIAL
DISCIPLINE SPECIFIC
LONGITUDINAL
INTEGRATED
Hirsh DA, Ogur B, Thibault GE, Cox M. New Models of Clinical Education: “Continuity”
as an Organizing Principle for Clinical Clerkships. New Engl J Med (in press, 2007)
Continuity of Care
• Goal
– Enhanced patient connection, caring and
advocacy
• Educational Prerequisites
– Contact with patients at the site and time of
initial medical decision making
– Ability to follow patients across care venues
• Operational Requirements
– Longitudinal patient care experiences
Continuity of Curriculum
• Goal
– Enhanced knowledge acquisition, transfer and
meta-cognition
• Educational Prerequisites
– Developmentally appropriate acquisition of
relevant core competencies and competencybased assessment
• Operational Requirements
– Interdisciplinary/interprofessional curriculum
organization and management
Continuity of Supervision
• Goal
– Enhanced role modeling, coaching and
mentoring
• Educational Prerequisites
– Community of learners, educators and
caregivers
• Operational Requirements
– Longitudinal learner oversight
ORIENTATION
Core Faculty
Other Caregivers
Student Practice
Patients
Team Learning
Individualized Learning
ORIENTATION
Core Faculty
Other Caregivers
Student Practice
Inpatient/Acute
Team Learning
Individualized Learning
Outpatient
ORIENTATION
Core Faculty
Other Caregivers
Student Practice
Other Faculty and Consultants
Team Learning
Individualized Learning
Cambridge Integrated Clerkship
Continuity of Care
CIC
CON
Chi-Square
Seen hospital patients before diagnosis and decision for admission?
Very Often/Often
Sometimes/Rarely/Never
100
9
0
90
0.000
Seen hospital patients you have treated after their discharge?
Very Often/Often
Sometimes/Rarely/Never
100
0
0
100
0.000
Been involved in establishing meaningful relationships with patients?
Very Often/Often
Sometimes/Rarely/Never
100
45
0
55
0.012
Cambridge Integrated Clerkship
Student Outcomes
CIC
CON
ALL
P
Combined NBME
Shelf Exams (%)
78.0
71.5
71.0
<0.001
4th Year OSCE (%)
70.0
63.9
60.8
< 0.01
Communication (%)
75.2
53.5
47.8
<0.001
NBME CCSSA*
513.8
398.9
nt
<0.05
pre
3.93
3.35
nt
NS
post
4.22
3.12
nt
<0.01
Tasks of
Medicine
Scale
*Comprehensive Clinical Science Self-Assessment Examination
Cambridge Integrated Clerkship
Self Awareness
Mean Difference Between Predicted and Actual Scores
200
150
CIC
CON
P < 0.05
100
50
0
163.33
48.13
Cambridge Integrated Clerkship
“Continuity of Idealism”
Extent to Which Experiences Have Prepared You To…?
(Mean scores:1=Very Poorly / 6=Very Well)
CIC
CON
P-value
Be truly caring in dealing with patients
5.63
4.00
0.000
Deal with ethical dilemmas
4.63
2.73
0.000
See how the social context affects patients
5.75
3.45
0.000
Relate well to a diverse patient population
5.63
4.09
0.015
Know your strengths and limitations
4.75
3.55
0.028
Medical Education
Among all of the Academic Health Center roles,
education will require the greatest changes in the
coming decade…. We regard education as one of
the primary mechanisms for initiating a cultural
shift toward an emphasis on the needs of patients
and populations and a focus on improving health,
using the best of science and the best of caring.
Institute of Medicine. Academic Health Centers:
Leading Change in the 21st Century (2003).
Health Professions Education
Paradigm Shifts
Traditional
New
Biological
Bio-Psycho-Social
Autonomy
Cooperation
Profession-Specific
Inter-Professional
Knowledge
Discovery
Individual Expertise
Collective Expertise
Discontinuous
Developmental
Assessment
Knowledge
Performance
Individual Excellence
Team Excellence
Progression
Time-Dependent
Competency-Dependent
Framework
Pedagogy
When you come to
a fork in the road…
Take It!
Yogi Berra