Monday, April 27, 2009

Symposium on Health Education Reform, Day One

WOW....surrounded by heavyweights...all of them.

Had breakfast with Polly Bednash, who is the Executive Director of the AACN, Darrell Kirch, the current president and CEO of the AAMC, and my friend, and colleague, VP of the AAPA Bill Fenn.

Attendees include:

President Emeritus AAMC
Chancellor Emory University
Director, Division of Undergraduate Medical Education, AMA
President and CEO of the Institute for Healthcare Improvement
Professor and Dean of Vanderbilt School of Nursing
CEO Henry Ford Medical Group
Senior VP of the American Board of Medical Specialties
CEO and Executive VP, American Colleges of Pharmacy
CEO Accreditation Council for CME
CEO National League Nursing
President and CEO ACGME
President American Association of Colleges of Osteopathic Medicine
Coordinating Producer ABC News Health Care Task Force

as well as NUMEROUS other deans and presidents of various medical schools.

It was a good day.

First session started with a review of the four cornerstones of health reform for the Mayo Clinic.

Discussion also focused around reforming medical student education to NOT teach disease treatment, but to teach healthcare delivery. There was a lot of focus on integrated classes for medical students, WITH MANY classes being taken with other health professionals. For example. Anatomy. There was discussion that medical students, nursing students, PT students, and PA students ALL TAKE THE SAME ANATOMY COURSES TOGETHER. There was talk about incorporating a course that would solely teach and focus on teamwork, and (sorry Happy) teaching the physician that they are an EQUAL with other members on the team, and not always in charge.

There was a lot of discussion about the Intermountain group, that manages 30,000 diabetic patients with only FOUR endocrinologists. HOW? They use non physician providers.

The next session was about Licensure, Accreditation, and Certification. There was a lot of debate about having a SOLITARY interdisciplinary certifcation process.

There was a talk about Professionalism, and having medical students NOT graded on individual exams to test medical knowledge that they won't remember, but to test them on the concepts, and the ability to find the answers when they need them. ALSO, to test them on HOW WELL THEY FUNCTION IN THE TEAM MODEL.

The next session included Realigning the Health Care Training System Toward Coordinated Patient Centered Care, again discussing the team model, and dramatically changing the current medical school structure.

Finally, we were asked to submit a singular answer from EVERY table as to HOW to best reform the health care system.

Then, we had dinner, and a discussion on Driving Change in Academic Medicine.

I'm tired now. A lot of information, a lot of very intense discussion amongst a group of highly accomplished and intelligent folks.

I will update you tomorrow with the findings at that time.

Here's some more information:

After the introduction, Denis Cortese, M.D., presented an overview of the Mayo Clinic Health Policy Center’s consensus-driven cornerstones for health care reform in America: create value, coordinate care, reform the payment system and insure everyone. He noted that medical education must play a crucial role in preparing individuals to provide high-value, coordinated care and introduced several issues for education professionals to consider, including specific curriculum designed to increase value, student selection criteria, instruction methods, assessment and financing.

Zoƫ Baird then introduced the panel and framed the discussion around how to train students to create a healthier America. All panelists agreed that the educational system must be redesigned to break down professional silos, creating an educational environment in which physicians, nurses, other allied health professionals, community health workers and family caregivers learn to work together on behalf of the patient.

“There is concern about a shortage of physicians today,” said Michael Johns, M.D. “I think if we gave allied health staff the ability to practice to the full extent of their skills, that shortage would be a lot smaller.

“We need the right person at the right time to provide leadership to the care team,” he continued. “Physicians need to be comfortable not being at point all the time. Every person is important.”

Panel members also noted that the curriculum must incorporate elements of engineering and health delivery science in addition to biological science.

Dr. Cortese commented that the current education system encourages learners to focus on accumulation of knowledge rather than innovative ways to deliver health care to individuals.

The group also called for the development of novel assessments – including measurement based upon patient outcomes, teamwork and individual performance.

“We need to move away from GPA and standard examinations as our primary or sole assessment tools,” said Jack Stobo, M.D. “There is no correlation between these tools and how students perform in practice.”

“We are in control of health professional education… it’s ours to win or lose,” he emphasized. “There currently is a mismatch with how we’re educating professionals and what society needs.”

10-11:30 a.m. – Licensure, Accreditation and Certification: Achieving Harmonic Resonance

Susan Wagner, Producer, Dr. Oz Show

Geraldine Bednash, Ph.D., Executive Director, American Association of Colleges
of Nursing
Claire Bender, M.D., Director for Education, Mayo Clinic in Minnesota
Richard Hawkins, M.D., Senior Vice President for Professional and
Scientific Affairs, American Board of Medical Specialties
Thomas Nasca, M.D., CEO, Accreditation Council for Graduate Medical Education

Moderator Susan Wagner provided introductions and began the discussion by asking the panelists to define licensure, accreditation and certification. Then, discussion revolved around identifying steps to change licensure, accreditation and certification standards/processes without a clear sense of what reforms will shape the care delivery system.

Geraldine Bednash, Ph.D., R.N., discussed efforts in advanced practice nursing to bring together the different standard-setting groups to agree on a common set of standards for certification and accreditation. Dr. Bednash noted that licensing occurs at the state level by government and is influenced more by political considerations instead of evidence of capability of providers.

Expanding sharing opportunities is an area that can be explored immediately, according to Claire Bender, M.D. Dr. Bender described new efforts at Mayo Clinic to bring different providers together in the same class when curriculum is applicable to both. It has been successful in demonstrating that different providers have and need different skills. The model also provides an environment that allows different health care professionals to become familiar with each other and respect the abilities of each type of provider.

Thomas Nasca, M.D., pointed out that it will be difficult to get hundreds of professional societies, accrediting bodies and licensure boards around the table, but that it may be possible to begin agreeing on unifying themes that move across discipline boundaries. It will be important to make sure that licensure, accreditation and certification standards don’t prohibit change, and reinforce core competencies that learners can carry forward as health care delivery systems evolve.

Richard Hawkins, M.D., discussed how assessments can be redefined to reinforce the principles of teamwork in a reformed health care environment. He suggested creating a feedback cycle from clinical care into the education and certification process.

Participants spent a portion of the session submitting ideas for changes in licensure, certification and accreditation to aid in transforming the educational system to support patient-centered, coordinated health care reform. The following actions received the highest endorsement.

Introduce team-based minimum standards for training and care models for both certification and accreditation.

Introduce team-based exercises as part of individual certification.

Certification should more closely mirror real-life clinical situations.

Consider use of a public/private entity, independent of Congress, to bring societies and professions together and adopt more common standards for training, certification and accreditation.

Noon-1:30 p.m. – Professionalism - The Critical Element in Health Care Education

If doctors falter in their professionalism, health care reform efforts will come up short, said Jordan Cohen, M.D., president emeritus of the Association of the American Medical Colleges and professor of medicine and public health at George Washington University.

“Professionalism is when physicians know the right thing to do and then do it,” he remarked in his keynote luncheon address. “It’s the behavior required of doctors in fulfilling their compact with society. They are honor bound on their own volition to work in patients’ best interest and use their knowledge and expertise to that end.”

Dr. Cohen said that nurturing professionalism is one way to advance needed changes in U.S. health care, and he recommended six ways for educators to promote professionalism:

Adopt and approve admission criteria. Few medical students fail to graduate and fewer still fail to get licensed. Educators have a fundamental role as gatekeepers to the profession.
Establish explicit learning objectives. Adults learn best when they have prospective understanding of what they are going to learn.
Address the rationale for adhering to the precepts of professionalism in the formal curriculum. Future physicians need to be mindful of temptations and ways to withstand conflicts of interest.
Be proactive and intentional in the informal curriculum. Educators need to model behaviors emblematic of professionalism. Informal curriculum is one of the most powerful influences on adopting the norms of the profession.
Articulate institutional expectations. “We need to be unabashed about communicating these expectations,” says Dr. Cohen.
Evaluate and reward behaviors that are emblematic of professionalism. Sanction and call out those who are not professional.

Americans long to trust their physicians and polls show that they largely do, Dr. Cohen added. And, trusting doctors is good for patients. “It increasing compliance and improves outcomes,” he remarked. “But that trust is earned, not owed. The surest way to lose that trust is to abandon professionalism.”

1:30-3 p.m. – Realigning the Health Care Training System for Coordinated Patient- Centered Care

Maggie Mahar, Ph.D., health care fellow, Century Foundation

Mark Kelly, M.D., Henry Ford Medical Group
Lindsey Henson, M.D., University of Minnesota
William Hersh, M.D., Oregon Health and Science University
Beverly Malone, PhD, RN, FAAN, National League of Nursing
Alyce Schultz, RN, PhD, FAAN, EBP Concepts

Today’s medical education system has holes that prevent the next generation of doctors, nurses and allied health professionals from learning how to provide patient-centered care.

That was the premise of moderator Maggie Mahar, Ph.D., health care fellow, Century Foundation, as she opened the session titled “Realigning the Health Care Training System for Coordinated Patient-Centered Care.”

She was joined by representatives from, nursing, medical education and medical center leadership to discuss how the core competencies identified in the Institute of Medicine’s 2003 report “Bridge to Quality” might fill those gaps.

Panel discussion centered on the core competencies, most taken from the IOM report, including:

Providing patient-centered care
Working in interdisciplinary teams
Using evidence-based practice
Applying quality improvement
Using informatics
Shifting culture toward professionalism

The discussion sparked more than 30 recommendations to keep patients at the center of coordinated care. The top-ranked recommendations encompassed common themes of teaching future providers how to work in teams and across disciplines. The recommendations challenged educators to find ways to increase learning opportunities in real world settings.

Participants ranked these recommendations as most important:

Introduce (early in training programs) team-based and reality-based standards and experiences that reflect all health care team members contributing at their highest level of training.

Establish an institutional/unit commitment to patient-centered collaborative care.

To understand patients, students should interface with the patients in their communities experiencing medical care through their patients eyes and experiences

Incentives for students (i.e. evaluation) must be aligned with team learning.

Health education schools need to work across disciplines to develop areas of shared curriculum to teach students team care delivery

Create a non-punitive culture for understanding and learning from mistakes and inefficiency

3:30-5 p.m. – Your Views Concerning Change – What is Required to Create the Health Care Workforce of the Future?

Event co-hosts Pat Mitchell and Dr. Cascino challenged participants to brainstorm ideas to answer the same question posed to MD Connector Competition participants:

“In order to create a health care workforce equipped to provide a high-value team approach to coordinated, patient-centered health care, what is the most important change required of the health care education system?”

The group spent an hour discussing potential changes, and submitted their consensus responses. Responses will be compiled during the evening, and participants will review and prioritize the recommendations during the opening session on Tuesday morning.

7-8 p.m. – Driving Change in Academic Medicine

Darrell Kirch, M.D., president and CEO, Association of American Medical Colleges provided perspective on the need for change in academic medicine.

Dr. Kirch emphasized the importance of focusing medical and health care education reform on the training of all professionals who work in the delivery of health care. Individuals who practice in any portion of care delivery are a vital part of the team approach to medicine and need to have a voice in the evolution of training.

Dr. Kirch noted that many buzzwords are associated with health care reform. One of these words is “change.” He focused on two degrees of change:

Incremental, which is usually considered good in academic settings, and
Revolutionary, which encompasses broad change

Dr. Kirch proposed the need for a middle ground in education: transformational change. This involves sweeping, fundamental change that recognizes the tremendous good in the current system – especially the dedicated people.

A primary barrier to change, he noted, is true culture shift in medical and health care education. Dr. Kirch cited the 1910 Flexner Report as the last true culture shift in medical and health care education. Flexner emphasized an academic culture which has medical research at its core. While this is a valid foundation, Dr. Kirsh said that this focus has led to competition among individuals in research and practice.

A New Culture
Dr. Kirch discussed that today’s patient expects teamwork in medicine. The current health care practice – which emphasizes individualism – is unsustainable, and there is broad recognition that teaching and learning have to be different. Health care professionals need to use information rather than retain information.

Dr. Kirch concluded his presentation by outlining five items for medical and health care education reform:

First, health care systems and educational systems need to be partners. This involves training organizations that are accountable for developing value in the health care system.

Second, the medical and health care training system needs to put aside culture and focus on training that meets the needs of patients.

Third, medical and health care education schools must be increasingly transparent with financial and tuition information.

Fourth, medical education must develop future leaders, building a bottom-up approach that focuses on teamwork and consensus.

Fifth, the health care system must examine the factors that drive medical and health care education training. This must include the concept of justice in the health care system. Dr. Kirch emphasized that the current health care system is unjust or fundamentally unfair, which is not a political issue but a core ethical issue.


Anonymous said...

Where was AMA representative? Why didn't they send a representative to this symposium? Seems senseless to have it if the Medical establishment is there for their input.

physasst said...

AMA did send a Rep as well. There was also the President of the American Board of Internal Medicine there. And the Executive director of the NBME was there as well. So there was a ton pf physician input. The AMA rep however, was not on the panels, and, I don't think their input would have changed anything. Less than 17% of current physicians even belong to the AMA. This was about Healthcare EDUCATION, not delivery system reform, although there are some links between the two. Most of the input was garnered from all of these other representatives, Mayo had a very limited number of voters. I was a non-voter there to represent the PA's. Our VP Bill Fenn, was voting. They took a definite step towards limiting the "mayo influence", and really wanted much more input from outside sources.

Anonymous said...

1. Sounds like a lot of platitudes, handwaving, Much Ado About Nothing, if you get my drift.

2. Having MDs/RNs/PAs/NPs/PTs/OTs/etc. all take the same anatomy class doesn't make sense, because the level of understanding required from each group is different.

3. "and (sorry Happy) teaching the physician that they are an EQUAL with other members on the team, and not always in charge." Sure, everybody's job is important and essential, but as the attending physician, I am the one in charge.

Anonymous said...

The child becomes the teacher or biting the hand the feeds you. You decide.